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Full text of "A system of surgery (Volume 6)"

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THE 

ABNER WELLBORN CALHOUN 

MEDICAL LIBRARY 

1923 




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SYSTEMof SURGERY, 

By BENJAMIN BELL. 
VOLUME SIXTH AND LAST. 



[Price Six Shillings and Six Pence in boards.] 



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SYSTEM 

O F 

SURGERY. 



B Y 



BENJAMIN BELL, 

MEMBER OF THE ROYAL COLLEGES OF SURGEONS 

OF IRELAND AND EDINBURGH, 

ONE OF THE SURGEONS TO THE ROYAL INFIRMARY, 

AND FELLOW OF THE ROYAL SOCIETY OF EDINBURGH. 



ILLUSTRATED WITH COPPERPLATES. 



VOLUME VI. 
THE THIRD EDITION. 




EDINBURGH: 

Printed for CHARLES ELLIOT, Edinburgh; 

C. ELLIOT & T. KAY, N» 332, Strand; and 

G. G. J. & J. R. O B I N S O N, London. 

JM 3 DCC,LXXXIX. 



THIS and the preceding Volumes 
comprehend the ■Syftem of Surgery 
which I had undertaken to publiih. 

To a candid public I am under great 
obligations. My labours have met with 
a reception more favourable than I expect- 
ed, and more flattering than they feem to 
me to merit* 

Different editions have already been 
publifhed of the preceding volumes. If 
the Work, now that it is nnifhed, con- 
tinues to have a fimilar reception, no at* 
tendon mail be wanting on my part to 
render it as complete as may be : I mean 
to infert in every edition to which it may 
extend, whatever improvements future 
experience may add to our flock of chi- 
rurgical knowledge. 

For this purpofe, I have already re- 

quefted the favour of my friends in dif- 

A 3 fercnt 



[ 6 ] 

ferent parts of the world, to give me early 
intelligence of every improvement with 
which they may become acquainted ; and 
I take this method of foliciting the fame 
kind of afhftance from others. In this 
manner, I ihall be enabled to render the 
work more perfect than I otherwife could 
do ; at the fame time that improvements 
may thus be preferved which otherwife 
might be loft. 

* To the purchafers of the firft editions, 

I think it a piece of juftice to obferve, 
that their intereft fhall not be affected, 
by any improvements that may be in- 
ferted in any fubfequent edition; for 
whenever the alterations are of much im- 
portance, the Bookfellers, both here and 
elfewhere, fhall be defired to fell them 
feparate from the reft of the Work. 

Benjamin Bell, 



bin. May ? 
1788. 5 



CONTENTS. 

CHAP. XXXIX. 

Page 

QTFractures 9 

SECTION I. 

General Obfervations on Fractures, - g 

SECTION II. 
OfFraclures of the Nofe, - 48 

SECTION III. 
Of Fractures of the Bones of the Face, 52 

SECTION IV. 
OfFraclures of the inferior maxillary Bones, 54 

SECTION V. 
Of Fractures of the Clavicles and Ribs, 5S 

SECTION VI. 
Of Fractures of the Sternum, 67 

SECTION VII. 
Of Fractures of the Vertebra, Os Sacrum, 
Coccyx, and OJfa Innominata, n \ 

SECTION VIII. 
Of Fractures of the Scapula, - 76 

SECTION IX. 
Of Fractures of the Humerus, - 70 

SECTION X. 
OfFraclures of the Bones of the Fore-arm, 84 

SEC- 



Tiii C O N T £ N T §. 

Pag« 

SECTION XI. 
Of FraBures of the Bones of the Wri/l, 
Hands and Fingers ; - * 9 1 

SECTION XII. 
Of FraBures of the Femur and Thigh-bone, 95 

SECTION XIII. 
Of FraBures of the Patella, - hi 

SECTION XIV. 
Of FraBures of the Bones of the Leg, 121 

SECTION XV. 
Of Frail ures of the Bones of the Foot and 
Toes, - - 130 

SECTION XVI. 

Of Compound FraBures^ - 132 

CHAP. XL. 

QTLUXATIONS, I57 

S E C T I O N I. 

General Remarks on Luxations, - 157 

SECTION II. 
Of luxations of the Bones of the Cranium, 1 8 3 

SECTION III. 
Of Luxations of the Bones of the Nofe, 1 84 

SECTION IV. 
Of Luxations of the Lower Jaw, - 1S6 

SECTION V. 
Of Luxations of the Head, * 192 

SEC- 



CONTENTS. ix 

Page 

SECTION VI. 

Of Luxations of the Spine, Os Sacrum, and 
Os Coccyx, - - 196 

SECTION VII. 
Of Luxations of the Clavicles, - 204 

SECTION VIII. 
Of Luxations of the Ribs, - 208 

SECTION IX. 
Of Di/locations of the Humerus at the Joint 
of the Shoulder, - - 211 

SECTION X. 
Of Luxations of the Fore-arm at the Joint 
of the Elbow, - - 239 

SECTION XL 
Of Luxations of the Bones of the Wrif, 246 

SECTION XII. 
Of Luxations of the Bones of the Meta- 
carpus and Fingers, - - 24.9 
SECTION XIII. 
Of Luxations of the Femur at the Hip-joint ,1$1 

SECTION XIV. 
Of Luxations of the Patella, - 267 

SECTION XV. 
Of Luxations of the 'Tibia and Fibula at 
fhe Joint of the Knee, - 269 

SEC- 



i CONTENTS. 

SECTION XVI. 

Of Luxations of the Foot at the Joint of 
the Ankle, - - 274 

SECTION XVII. 

Of Luxations of the Os Calcis, and other 
Bones of the Foot, - - 277 



CHAP. XLI. 

^/"Distorted Limbs, 



281 



CHAP. XLII. 
^Distortions of the Spine, . 294 

CHAP. XLIII. 

^Amputation, - - 301 

SECTION I. 
General Remarks on the Operation of Am- 
putation, - - jo 1 
SECTION II. 
Of the Caufes that may render Amputation 
neceffary, - «• 3° 3 
SECTION III. 
General Remarks on the Method of Ampu- 
tating Limbs, - - n 20 
S E C T I O N IV. 
Of Amputating the Thigh, - ^3$ 

S E C» 



CONTENTS. xi 

» P a g c 

SECTION V. 

Of Amputating the Leg, - 374 

SECTION VI. 
Of Amputating ivith a Flap, - 384 

SECTION VII. 
Of Amputating the 'Thigh at the Hip-joint, 3 8 S 

SECTION VIII. " 
Of the Flap Operation immediately above 
the Knee, - - 398 

SECTION IX. 
Of the Flap Operation below the Knee, 407 

SECTION X. 
Of Amputating the Foot, Toes, and Fingers, 411 

SECTION XI. 
Of Amputating the Arm at the Joint of 
the Shoulder, - - 417 

SECTION XII. 
Of Amputating the Arm, - 425 

CHAP. XLIV. 
Of Removing the Ends of Bones in Dif- 
eqfes of the Joints, - 427 

CHAP. XLV. 

Of Preventing or Dimini/hinq Pain in 

Chirursical Operations, 437 

CHAP, 



xii CONTENTS. 

Page 

CHAP. XL VI. 

QfMlDWIFERY, - 442 

SECTION I. 

General Obfervatiofts on Midwifery , 442 

SECTION II. 
Of the Ctefarean Operation, - 446 

SECTION III. 
Of the Divifion of the Symphyfis Pubis, 453 

CHAP. XL VII. 

Of Opening Dead Bodies, 460 

CHAP. XL VIII. 
Of Embalming, - - 465 

CHAP. XLIX. 
Of Bandages, - - 469 

Explanation of the Plates, 481 



A System 



TREATISE 

ON THE 

THEORY and PRACTICE 

O F 

SURGERY. 

CHAPTER XXXIX. 
Of Fractures. 

SECTION I. 

General Obfervations on ,Fra£tures. 

SOME practitioners denominate every 
folution of continuity in a bone a 
Fracture ; but the term may, with 
more propriety, be confined to thofe 
divifions in bones which are produced 
by external violence. Thus, we do not 
Vol. VI. B fay 



IO General Obfervailons Ch. XXXDC 

fay that a bone is fractured, the parts 
of winch are feparated from each other 
by the effect of any internal diforder ; 
while we fay that it is fractured when 
this happens from a fall, a blew, or a 
bruife. 

Fractures are of various kinds, and 
are diftmguiihed by different names. A 
bone may be fractured either directly 
acrofs, in an oblique direction, or longi^ 
tudinally : Kence the terms, Tranfverfe, 
Oblique, and Longitudinal Fractures. 
When a bone is fplit into fmall pieces, 
we call it a Splintered Fracture. 

When the teguments remain found, a 
fracture of a bone is denominated Simple ? 
and we term it Compound when the frac- 
ture communicates with a wound in the 
fkin, and other correfponding foft parts. 
By fome a fracture is faid to be Compound 
when a bone is broken into different parts j 
and thofe fractures they term Complica- 
ted, which are accompanied with wounds 
in the correfponding foft parts. This 
{ubdivifion, however, of fractures, ieems- 

to 



Sect, t. ■ b?i Fractures. Xt 

to be unnecefTary : for unlefs a bone is 
fplintered, no effential difference arifes 
merely from its being broke at one or 
two parts ; whereas the flighted commu- 
nication between a fracture and a wound 
in the furrounding foft parts, is apt to 
change the nature of it fo entirely, as to 
induce danger, and even death, in cafes 
where no alarming fymptoms Would o- 
therwife have been dreaded. 

The exiftence of fracture is, for the 
mod part, eafily difcovered by manual 
examination. A fracture of a fingle bone,; 
where there is only one in the fractured 
part of a limb, and the fracture of both 
bortes when there are two, as well as a 
fracture accompanied with an exten- 
live wound of the contiguous foft parts, 
are eafily detected : But in fimple frac- 
tures, where only one bone of a limb 
has fufFered, it is often difficult to judge 
with any degree of precifion ; and more 
particularly fo where the contiguous 
parts have become tenfe and painful be- 
fore a practitioner is called. In fuch 
cafes, our opinion muft be formed by a* 
B 2 minute 



1 2 General Obfcrvafions Ch. XXXlX. 

minute attention to different circumftan- 
ees : The age and habit of body of the 
patient ; the fite of the fuppofed fracture y 
the fituation of the limb when the injury 
was received ; and, laftly, to the attend- 
ing fymptoms. 

In old people, bones are fractured more 
eafily than in thofe who are at an earlier 
period of life. In infancy, bones will 
rather yield than break upon the applica- 
tion of a moderate force ; whilft in old 
age they become fo brittle, that the largefl 
in the body are frequently broke upon, 
the rnofl trifling falls and bruifes. 

Different difeafes induce this brittle 
Hate of the bones, particularly the lues 
venerea. Of this I have met with feve- 
ral inftances. In two cafes, the largefl 
and hardeft bones were broke folely by 
the ordinary action of the mufcles of the 
limb. It is alfo the effect of the fea~ 
fcurvy : bones that have been fractured 
and long united having been frequently 
feparated in advanced ftages of the real 
fcurvy, the callus being either difTolved 

or 



"Se<5t. I. on FraSliire-s. • 13 

or rendered too foft for the pnrpofe of 
retaining them together. 

Befides thefe general affections of the 
body, the bones themfelves are liable to 
a difeafe which renders them foft and 
flexible. It is ufually termed Mollities 
Offium. In fome cafes, it goes no farther 
than to produce that flate of the bones 
we have mentioned, in which they are 
apt to be fractured by flight falls, and 
other fimilar accidents : But in others, it 
has been known to proceed to fuch a 
height, that every bone in the body has 
become crooked and diflortecl. I have 
feen a fkeleton in which the condyles 
of the knee-joints were turned up to the 
pubes, and in which every other bone 
was crooked in nearly a fimilar degree. 

In judging therefore of the probabili- 
ty of a fracture from the degree of vio- 
lence applied, thefe circumftances deferve 
particular attention : For it is evident, 
that in old a*ge, and in the difeafed flates 
of bones we have mentioned, a degree of 
force will occalion fracture, which in 
B 3 other 



14 Qeneral Qbfervationf Ch. XXXlX r 

other fituations would not be equal to 
this effea. 

The fite of a fuppofed fracture is alfo 
to be taken into confideration. Bones 
are more apt to be broke in thofe places 
where they are hard and brittle, as in 
the firmer parts of all the long bones, 
than towards their extremities, where 
they are of a more foft and yielding tex- 
ture ; and bones that ly deep under the 
cover and protection of mufcular parts, 
as in the thighs, are not fo frequently 
fractured as t}\ofe of the arms and legs 
that are not fo well protected. 

Further, the fituafion of a limb when 
an injury is inflicted, is an object of 
inquiry. Thus, a very inconfiderable 
weight palling over a bone lying on an 
unequal furface will readily produce a 
fracture ; while the fame bone, equally 
fupported, will bear a heavy load without 
being injured. 

In forming an opinion of the probabi- 
lity of a fracture having taken place, we 
ought, laftly, to take into confideration 
tjie fymptoms which ufually accompany 

frac? 



Seel. I. vn Fra&itra. 1 5 

fra&ure. Thefe are, pain, fwelling, and 
tenfion in the contiguous parts ; a more 
or lefs crooked and dillorted Hate of the 
limb ; a crackling or grating noife on 
the parts being handled ; and lofs of 
power to a certain extent in the injured 
limb. 

It is true, that the mere fracture of a 
bone is not necefTarily attended with much 
pain ; for the bones, not being fo plen- 
tifully fupplied with nerves as the fbfter 
parts of the body, they are therefore of 
a lefs irritable nature. But pain arifes 
from two circumflances with which frac- 
tures are ufually attended ; the conti- 
guous foft parts being bruifed and other- 
wife hurt, in the firft place by the force 
producing the injury, and afterwards by 
the difplaced ends of the bones. For the 
moft part the pain indeed is not very fe- 
vere : but in fome cafes it becomes fo 
-violent as to be productive of the molt 
alarming fymptoms ; fpafrnodic aifeclions 
erf the mufcles in the injured limb ; high 
degrees of inflammation ; fever, accom- 
panied with fubfultus tendinum ; general 
B 4 cor> 



1 6 General Obfervations Ch. XXXIX, 

convulsions and delirium ; and if the 
caufe by which thefe fymptoms were in- 
duced be not foon obviated, they very 
commonly terminate in the death of the 
patient. In general this is preceded by 
mortification of the parts contiguous to 
the fracture ; but in fome inftances, af- 
fections of this kind prove fatal from the 
violence of the fever, and without any 
tendency to gangrene being perceptible. 

When the force by which a fracture 
is produced has been extenfively applied 
over a limb, we may readily fuppofe that 
the fevereft fymptoms may be induced by 
this caufe alone ; but in general it will 
be found, when the pain, tenfion, and 
convulfive twitchings of the mufcles are 
violent, that they chiefly originate from 
the ajdoining membranes, m'ufcles, or 
other foft parts being lacerated, punctu- 
red, or compreffed by the ends of the 
fractured bones : And although this may 
happen in fractures of every defcription, 
yet it will necefTarily be a more frequent 
occurrence in thofe that are fo oblique 
as to admit of the bones pafling eafily 

oyer 



Seel. I. On FraRurcs, 1 7 

over each other, than in tranfverfe frac- 
tures, where the parts, on being replaced, 
more readily remain in their natural u- 
tuation. 

The other diagnoftic fymptoms of 
fracture we enumerated, a grating noife 
on the parts being handled, and distor- 
tion and lofs of power to a • certain ex- 
tent in the injured limb, will be found 
on a minute examination to accompany 
almoft every accident of this kind. They 
will indeed be much more evident in 
fome fractures than in others : but in all 
they may be difcovered where the parts 
' are not much fwelled, excepting in the 
cafe of a longitudinal fracture. A bone 
may indeed be fplit in this direction, 
without any of thefe fymptons taking 
place : for unlefs the divided parts be 
completely feparated from each other, 
neither diftortion nor crackling will be 
perceived on handling them ; nor will 
the bone be rendered incapable of fu- 
ftaining thofe parts of the body which 
ufually reft on it. In fuch cafes, we 
judge of the probability of a fracture 

having 



X.8 General Obfirvations Ch.XXXIX* 

having happened, from the violence of 
the injury, the feverity of the fymptoms, 
and other circumftances already enume- 
rated. 

Befides thefe leading fymptoms of frac- 
tures which take place immediately on 
the injury being inflicted, there are 
others which occalionally occur from 
the *irft, and fome which we are to con- 
fider as confequences rather than fvmp- 
tcms. Of the nrft, the mod remarkable 
are, that great degree of ecchymofis 
which in fomc cafes appears inftantane- 
oufly, from the ends of the fractured 
bones having penetrated a contiguous 
artery or vein ; and the wound or lace- 
ration of the teguments in compound 
fractures. 

The moll important confequences of 
fractures are, ftiffnefs and immobility of 
the injured limb ; diftortion of the parts 
chiefly affected, either from a fulnefs or 
thicknefs remaining in the contiguous 
mufcles or ligaments ; an exuberancy of 
callus ; a contracted ftate of the conti- 
guous joints j or a marafmus or wafting 

of 



Sect. I. On F?'a£fures. 19 

of the limb itfelf. All thefe we mall 
confider more particularly when we 
come to fpeak of the treatment of frac- 
tures. 

In judging of a fracture, and the pro- 
bable event of it, various circumftances 
are to be confidered : particularly the 
age and habit of body of the patient ; 
the fituation of the bone, and the part of 
it that is injured ; the nature of the at- 
tending fymptoms ; the circumftances 
with which the fracture may be compli- 
cated j and the kind of fracture. 

With refpect to the firft of thefe, 
namely, the age and habit of body of 
the patient, we all know that they are 
points of much importance in the cure 
of every injury to which the human bo- 
dy is liable ; and in none more than in 
fractures. Thus in youth, particularly in 
infancy, fractures in general cure much 
more quickly than in old age ; and in 
found healthy conftitutions, much more 
readily than in fuch as are difeafed. We 
have obferved above, that the bones are 

3P$ 



20 General Obfervathns Ch.XXXIX. 

apt to become very bristle in lues vene- 
rea ; and it may here be remarked, that 
the exiftence of that difeafe, or of fcur- 
vy, is found to be particularly adverfe to 
the reunion of fractured parts. I have 
met with fome exceptions to this, where 
fractures have been eafily cured even in 
advanced ftages of the lues venerea : but 
there is much reafon to think that this 
is not a common occurrence ; and that 
where this difeafe has attacked the bones, 
no callus will form till the virus be era- 
dicated. 

In fpeaking of the effect of age on 
the cure of fractures, although I admit 
that the divided parts of bones unite 
more fpeedily in infancy than in old age, 
yet I think it right to remark, that it 
does not appear to happen with more 
certainty. By many we are told, that in 
advanced periods of life the union of 
fractured bones is often not to be ac- 
compliihed. I have never, however, 
feen an inftance of this, although I have 



Sect. I. On FraEiares. 2 1 

had the management of many fractures 
even in extreme old age. 

The foliation and part of the bone tl&t 
is injured, are both circumftances requi- 
ring attention. Thus we know, that 
fractures of the fmall bones of the arms 
and legs, of the feet and hands, and of 
the ribs, in general heal quickly and. 
eafily ; while fractures of the larger 
bones, particularly of the femur and hu- 
merus, are managed with much more 
difficulty. In the laft, indeed, one prin- 
cipal caufe of the cure proving for the 
moil part very tedious, is the difficulty 
of retaining the ends of the fractured 
bones together. But whatever the caufe 
may be, it will necefTarily have the fame 
effect on our prognofis. 

When any of the large bones are frac- 
tured near to their extremities, we find 
the danger to be much greater, and the 
profpect of a complete cure much lefs, 
than when they are broke near to their 
middle : For here the fliortnefs of one 
end of the bone makes the retention of 

it 



22 General Obfervations Ch.XXXfX. 

it difficult ; and the fymptoms which en- 
fue from a fracture in this fituation are 
apt to be particularly fevere, not only 
from the contiguity of the capfular liga- 
ments of the joints, which may thus be 
injured, but from the numerous tendons 
inferted into thefe parts of the bones ; 
which may not only be lacerated and 
bruifed, but even tore from their in- 
fertions. Befides, the ends of bones 
are not only foft, but even fpongy or 
cellular in their texture : Hence frac- 
tures near the extremities of bones are 
more tedious in the cure, and give rife 
to more troublefome fymptoms, than in 
the harder parts of them : for the frac- 
tured parts do not here unite with fuch 
equality ; they more frequently exfo- 
liate, and matter is more apt to form in 
them. 

It is alfo proper to remark, that frac- 
tures near the extremities of bones are 
frequently productive of ftifF immove- 
able joints, unwieldy limbs, pains and 
fwellings ; which, in various inftances, 

even 



Sect. I. on Traftures. 2$ 

even under the beft treatment, continue 
obftinate for a great length of time, and 
in fome cafes during the life of the pa- 
tient. 

We are in general led to flippofe, 
that thefe confequences are folely owing 
to mifmanagement, either on the part of 
the furgeon or of the patient. That in 
fome cafes they are fo, no perfon will 
deny. The ends of a fractured bbne 
may be improperly placed from the firfl 
by the practitioner, or they may be af- 
terwards mifplaced by the patient ; and 
in either cafe we may readily imagine, 
that all the fymptoms we have mention- 
ed will take place. But in juftice to the 
profeihon, we muft obferve, that they are 
more frequently to be attributed to the 
fituation and nature of the fracture than 
to any other caufe. Nor is it furprifing 
that it fhould be fo. When we confider 
the various circumftances with which a 
fracture is often accompanied ; the degree 
of violence required to break a large 
bone ; the fevere contufion of the conti- 
guous foft parts which this muft pro- 
duce ; 



54 General Obfcrvalicns Ch. XXXIX* 

duce ; and the laceration of nerves, 
mufcles, and ligaments, which muft oc- 
cur from the fpiculae of the fractured 
portions of bone ; we ihould rather be 
apt to fuppofe that they would be more 
frequently productive of troublefome 
confequences than we actually find to be 
the cafe. 

In forming a judgment of the nature 
and probable event of fractures, the 
fyrnptoms which take place merit par- 
ticular attention. If the fyrnptoms 
are moderate, when compared with the 
apparent degree of violence the parts 
have fufTered, our prognofis fhould be 
proportionably favourable : But when- 
ever the attending fyrnptoms are fevere, 
particularly if the pain be uncommonly 
violent, and the fwelling and tenfion 
confiderable, however trifling the force 
may have been by which the fracture 
was produced, the cafe will probably be 
difficult to manage, and uncertain in the 
event. In fuch circumftances, therefore, 
even in what is ufually termed a Simple 

Fracture, 



Se«5i. I. on FraBures, 25 

Fracture, our prognofis mould be guarded. 

The circurnftances with which a frac- 
ture may be complicated, are likewife of 
importance ; and unlefs they are duly 
weighed, no accurate judgment can be 
formed of the event. The contiguous 
mufcles and other foft parts may be fe- 
verely contufed ; fome of the ligaments 
and tendons of the injured part may be 
ruptured, or even tore from their infer- 
tions ; and the fracture may be. combined 
with a diflocation of one or both of the 
contiguous joints. Thefe accidents ag- 
gravate the danger in every cafe of frac- 
ture. 

The laft confideration on this fubject 
refpects the kind of fracture. The great- 
eft difference is obferved between the 
event of a fimple and of a compound 
fracture. A great proportion of cafes of 
fimple fracture are of a mild nature from 
the firfl ; and with very ordinary atten- 
tion complete cures are obtained: But 
in compound fractures, the fmallefl ex- 
ternal wound communicating with the 

Vol. VI. C in- 



2& General Obfervations. Ch.XXXKC 

injury in the bone, will often be produc-. 
tive of the greateft danger. I do not 
mean to fay that this i happens in every 
cafe ; on the contrary, we know that 
even the worft cafes of compound frac- 
tures will, with proper attention, often 
terminate in the moft favourable man- 
ner ; But every practitioner much ver- 
fant in this branch of bufinefs will allow 
that this is not to be depended on j 
and that even under the beft manage- 
ment fuch cafes are fo apt to go wrong,, 
as to warrant the opinion we have given 
of them, and to render it proper in al- 
mofl every iriftance to give a guarded 
prognofis. 

Authors lay down various indications 
for the cure of fractures ; and thefe we 
are delired to have flrictly in view : 
Namely, extenfion ; counter extenfion j 
coaptation, or replacement of the frac- 
tured parts ; deligation, in fo far as is 
neceffary for retaining them j pofition of 
the injured part ; and prevention or re- 
moval of bad fymptoms. 

The 



Sect. I. on FraBures. 27 

The fubject, however, may be Ampli- 
fied, and the indications with propriety 
reftricted to three : To replace the parts 
of the bone that have been moved from 
their natural fituation ; to retain them 
in this fituation as long as may be necef- 
fary ; and to obviate fuch fymptoms as 
may fupervene during the cure. 

In fome few favourable cafes, where 
the bones are fractured directly acrofs, 
they are either not moved out of their 
natural fituation, or the alteration is fo in- 
confiderable that they are eafily replaced. 
But when the bones of a limb are broke 
in an oblique direction, they are apt to 
pafs one another fo as to product much 
deformity and pain. The contiguous 
mufcles are thus feverely injured, and 
excited to violent action : Hence in all 
fuch affections the malady is increafed 
by every natural exertion either of the 
whole body or of the part more imme- 
diately injured ; and nothing will remove 
it but an artificial replacement of the 
diftorted bones. 

C 2 To 



2 8 General Obferuations Ch. XXXI3C 

To accomplifh this, various methods 
have been propofed. In former times it 
was effected by much violence and force ;, 
by what was termed Extenfion and Coun-* 
ter Extenfion : but we now know that our 
purpofe may be accomplifhed in an eafier 
manner, with lefs pain to the patient,, 
and lefs trouble to the operator. 

As long as it was imagined that much 
force ought to be employed, the limb 
was extended by one or more affrftants 
pulling at each end of it ; and when this 
was not fumcient to draw the bones into- 
their natural lituation, different machines 
were ufed for this purpofe. The necef- 
fary force was in general applied while 
the limb was on the ftretch ; a circum- 
ftance which added much to the difficul- 
ty of reducing the fractured parts of the 
bone : for in this manner all the conti- 
guous mufcles were put into action ; nor 
could the bones be replaced till this was- 
overcome by the application of a fupe- 
rior force. The mifchief which this 

would- 



Sect. I. on Fraffures. 29 

would often produce, it is eafier to ima- 
gine than to exprefs. 

When it is confidered, that in the re- 
duction of a fractured bone the chief re- 
finance we meet with is the action of 
the neighbouring mufcles, the propriety 
of putting the limb into fuch a pofture 
during the operation, as favours the re- 
laxation of the different mufcles connect- 
ed with it, is fo obvious, that we now 
reflect with furprife, that it was left to 
the practitioners of the prefent age to 
propofe this meafure. For, whatever 
may have been the ideas of a few indi- 
viduals, it is certain, that till very lately 
it was the general practice to keep every 
limb in an extended pofition while any 
attempt was making to replace the frac- 
tured bones, and that it is chiefly to Mr 
Pott we owe the introduction of the con- 
trary, practice. 

- In the treatment of a fracture, if we 
take care to relax all the mufcles of the 
limb, it is furprifing with what eaie the 
v ends of the bones may in general be re- 
C 3 placed. 



30 General Obfervations Ch. XXXIX. 

placed. When a limb is laid completely 
in this relaxed pofture, the furgeon will 
in mod cafes be able to replace them 
without any afiiftance whatever : But 
when he does not fucceed, a flight de- 
gree of extension may be employed, by 
the upper part of the limb being kept 
firm by one afliftant with his hands pla- 
ced between the fracture and the conti- 
guous joint, while the under part of it 
is gently extended by another ; care be- 
ing flill taken, however, to keep the 
mufcles as much relaxed as poflible. 

As it is of the utmoft importance in 
replacing the fractured parts* of the bone 
to do it with exaclnefs, the niceft atten- 
tion mould be paid to this part of the 
operation. Every inequality depending 
upon any portion of bone being difpla- 
ced mould be removed, fo as to render 
the injured part as fimilar as poflible to 
the correfpondirig found limb ; which, 
for the purpofe of a more attentive exa- 
mination, mould be placed as near to it 

as 



Sect. I. on FraElures. 31 

as the conveniency of the operator will 
permit. 

The neceflity of attention to this part 
of the treatment will appear from this, 
that when the fractured bones are not 
properly reduced at firft, the limb muft 
either, remain always diftorted, or it 
muft be put right during a future flage 
of the treatment ; when it will necefTari- 
ly be done with more pain to the patient, 
and more trouble and perplexity to the 
furgeon. 

The bones being put right, our next 
object is to retain them in this fituation 
as long as may be neceffary. This we 
do by proper compreffes and bandages, 
and by placing the limb in fuch a ftate 
of relaxation as will admit of its refting 
with eafe, and without being disturbed, 
till the cure be completed. When we 
come to treat of fractures of particular 
parts, the pofture in which they mould 
be placed, and the bandages that appear 
to be bell adapted to them, will be de- 
fcribed. At prefent we may obferve, 
C 4 that" 



2,2 General Obfervations Ch. XXXIX. 

that no bandage fliould be applied with 
more tightnefs than is neceffary for re- 
taining the bones in their iituation ; and 
that this may, for the moil part, be eafily 
effected, if the limb be kept in fach a 
pofture as to relax the various mufcles 
connected with it. 

The time required for rendering the 
union of fractured bones fufEciently 
firm, depends upon various circum- 
flances : Upon the fize of the bone, and 
the weight which it has to fupport ; on 
the age and habit of body of the patient ; 
and on the cure having proceeded with 
more or lefs interruption, from the limb 
having been kept more or lefs fteadily in 
its htuation, as well as from the attend- 
ing fymptoms of fwelling, pain, and 
inflammation, having been mild or fe- 
vere. In a healthy middle-aged patient* 
when no untoward fymptoms have oc- 
curred, and when the injured parts have 
been retained exactly in their fituation, 
a cure of a fractured femur, or of the 
bones of the leg, will be accomplifh- 

'ed 



Sect. I. on Frafiures. 33 

ed in two months ; of the humerus and 
bones of the fore-arm, in fix weeks 4 
of the clavicles, ribs, and bones of the 
fingers and toes, hands and feet, in 
three weeks. In infancy and child- 
hood, fractures in all thefe parts heal 
much more quickly ; while in old age 
this uniting procefs goes on more flowly, 
and therefore requires more time to ac- 
complifh. 

In fimple fractures, to which thefe ge- 
neral obfervations more particularly ap- 
ply, the pain, tenfion, and other fymp- 
toms, are in general moderate, and ufual- 
ly fubfide entirely in the courfe of a few 
days, if the bones be properly retained 
in their fituation ; but in fome cafes, in- 
ftead of diminifhing, they become daily 
more violent, fo as to be productive of 
much diftrefs to the patient, as well as 
trouble and ernbarraffment to the practi- 
tioner. 

When the mufcles and other foft parts 
of the limb have not been much contu- 
fed, there is perhaps no neceflity for any 

application, 



34 General Obfervations Ch. XXXIX. 

application, with a view to the prevention 
either of pain or tenfion : but for the mod 
part it is proper to guard againft the vio»- 
lence of thefe fyftrptoms, by the early 
ufe of fome aftringent applications, fuch 
as, a folution of faccharum faturni, of 
crude fal ammoniac, or fpiritus Minde- 
reri ; and when thefe fail, by a free ap- 
plication of leeches over all the pained 
parts. Indeed, the practice of taking 
away blood by leeches proves in every 
cafe of this kind fo beneficial, that I al- 
ways advife it whenever the tenfion is in 
any degree confiderable, or whenever 
the pain continues fevere after the bones 
have been replaced. In every cafe of 
fracture, inflammation is the fymptom 
which, in the firfl place, we have moft 
reafon to dread ; and as nothing tends 
with fuch certainty to prevent or remove 
it as local blood-letting, it fhould never 
be omitted when the furrounding fbft 
parts are much injured : Nor fhould the 
practice be delayed after it appears to be 

in 



Sect. I. on FraBures. 35 

in any degree necefTary ; for it proves al- 
ways moft effectual when employed foon 
after an injury has been inflicted. 

Befides the immediate advantage of 
relieving the pain in the injured part, 
nothing prevents with fuch certainty the 
troublefome confequences of contufion 
in cafes of fracture as the early applica- 
tion of leeches. Of thefe confequences, 
the moft remarkable are, deep-feated ab- 
fceffes, which in fome inftances form 
within the cavity of the bone itfelf, and 
in others in the furrounding cellular fub- 
ftance ; long continued pains, refembling 
rheumatic»affections, flretching over the 
injured limb ; a thickened enlarged ftate 
of the periofteum and other foft parts ; 
,a ftiff contracted flate of the contiguous 
tendons ; an exuberancy of callus ; and 
an unwieldy ftate of the whole mem- 
ber. 

It is well known to all who are ver- 
fant in this branch of bulinefs, that all of 
thefe confequences are apt to fucceed to* 
fractures accompanied with much con- 
tufion : 



36 General Olfervations Ch. XXXIX. 

iufion: And nothing proves more per- 
plexing to furgeons, or more diftrefsful 
to patients ; for when they are not foon 
removed, they are ver.y apt to prove per- 
manent ; and for the moil part they are 
attributed to fome mifmanagement in the 
reduction of the fracture. 

In many inftances they no doubt arife 
from the extremities of the fractured 
bone not being properly replaced, or not 
retained with exactnefs afterwards : but 
they more frequently proceed from the 
inflammation which follows from contu- 
fion. It is therefore evident, that early 
leeching can alone be ufeful. When 
fwelling and pain in a fractured limb 
have continued long, the mod effectual 
relief is obtained from frictions with 
emollient oils, and from warm bathing, 
particularly from a proper ufe of the 
waters of Buxton, Bath, and Barreges. 

We are fometimes difappointed in ob- 
taining complete cures of fractures, by 
the limbs remaining unfeemly from an 
over-growth of callus. It is not a com- 
mon 



Seel. I. on Trafiures. 37 

mon occurrence ; but every practitioner 
rnuft have met with it. As far as I am 
able to judge, in fractures attended with 
much inflammation, where this incon- 
veniency is moft apt to occur, local 
blood-letting proves more ufefui than 
any other remedy in preventing it. In 
fome cafes, however, the tendency to 
form callus is fo great that it can fcarce- 
ly be checked. The application of ar- 
dent fpirits, and of other aftringents, is 
here fuppofed to prove ufefui ; and I 
have in fome instances derived advantage 
from a continued gentle prefTure, which 
is beft applied by means of a thin plate 
of lead adapted to the form of the part, 
and retained by a proper bandage : But 
as neither this nor any other remedy will 
prove fuccefsful in every cafe, and as pa- 
tients are apt to regret nothing fo much 
as a disappointment in obtaining a com- 
plete cure of a fracture, our fafefb courfe, 
as foon as the callus begins to be too 
luxuriant, is to acquaint the patient with 
the probable event ; and he mud be ve- 
ry 



38 General Obfervations Ch. XXXD^ 

ry unreafonable indeed, if he afterwards 
repines at what the utmoft care and at- 
tention could not prevent. 

Among the confequences which fome- 
times refult from fractures, there is one 
which we muft confider more particular- 
ly ; namely, a difficulty of obtaining an 
union between the ends of the fractured 
bones, by which they remain loofe and 
detached long after they mould have 
been firmly knitted together. 

This may proceed from various caufes : 
From fome conftitutional difeafe, fuch as 
rickets, fcurvy, or lues venerea; from 
the ends of the fractured bones not be- 
ing kept fteadily in contact till their 
complete reunion be accomplimed ; from 
a portion of a mufcle, tendon, or liga- 
ment, falling in between the ends of the 
fractured parts, fo as to prevent them 
from being placed in contact; and in 
fome cafes it proceeds from a bone be- 
ing broke in different parts, and the in- 
termediate detached pieces being fo fmall 

as 



Sect. I. On FraBurei. 39 

as to prevent them from adhering, even 
when kept in clofe contact. 

It has been obferved, too, that occur- 
rences of this kind happen more fre- 
quently during pregnancy than in other 
fituations. This has not indeed fallen 
within my obfervation ; but it appears 
to be the general opinion of practitioners* 
and different inftances of it are recorded 
by authors. 

When this want of union proceeds 
from any general difeafe of the fyftem, 
thofe remedies muft be employed which 
are known to prove molt effectual in re- 
moving it : For no attention on the part 
of the furgeon will produce any advan- 
tage till this be accomplifhed ; and as 
much mifchief is often prevented by an 
early application of remedies, they 
fhould always be advifed as foon as the 
caufe is obferved to exift. It would 
even be a proper precaution, where it is 
known that a patient at the time of re- 
ceiving a fracture labours under any con- 
ftitutional diforder, to advife fuch a 

courfe 



40 General Obfervations Cli. XXXIX." 

courfe immediately ; by which means 
cures might be accelerated, which other- 
wife would be unnecefTarily protracted. 

When the union has been prevented 
by the fractured bones not having been 
kept fteadily in -a proper Situation, the 
bones fhould be replaced and retained in 
their fituation with as much exactnefs as 
poflible ; and when the injury is ftill re- 
cent, a perfect union may by this means 
be ftill accomplifhed. 

But where a fracture has continued 
long without any union being formed 
between the ends of the bones, the ofTe- 
ous matter by which they fhould have 
been knit. together becomes hard, fmooth, 
and totally unfit for the purpofe, in fo 
much that no advantage could be deri- 
ved from their being replaced. Of this 
I have met with different inftances, 
where the ends of the fractured bones 
were become perfectly fmooth, and mo- 
ved on each other with the fame eafe 
and freedom as the bones of any of the 

joints : 



Sect. I. on Frafiures. 41 

joints : and various cafes of it are to be 
met with in authors. 

In this fituation, when no great incon- 
v^niency is experienced, the patient 
ihould be advifed to fubmit to it, parti- 
cularly in fractures of the fmall bones, 
fuch as thole of the fingers and toes, the 
bones of the metacarpus and metatarfus, 
the clavicles, and ribs : but in the large 
bones of the extremities, where much 
firmnefs is required, and where any in- 
jury of this kind mufl be productive of 
almoft a total lofs of the ufe of the limb, 
as we may be able by an operation to re- 
ftore it, we ought perhaps in every in- 
ftance to propofe it. By making an in- 
cifion through the furrounding foft parts, 
fo as to lay the ends of the bones bare, 
and removing a fmall portion of each of" 
them either with a common faw or with 
the head of a trepan, we reduce them to 
the ftate of a recent fracture ; when, by 
taking care to retain them in a proper 
fituation, we may in due time expect a 
complete cure. 

Vol. VI. D The* 



A"2 General Obfervations Ch. XXXIX. 

The operation is no doubt painful and 
tedious : for the incifion mould be exten- 
five, in order to admit of a free appli- 
cation of the inftruments ; and for the 
moft part it mud be conducted with 
much caution, in order to avoid the large 
blood-veffels of the limb : But it may be 
done with perfect fafety by any perfon 
accuftomed to the operative part of fur- 
gery *. 

- Nor mould we be deterred from pro- 
posing this method of cure, from any ap- 
prehenfion about the extent of the va- 
cancy that may be produced by the re- 
moval of the ends of the bones : for if 
the limb be kept fteadily in its fituation^ 
and if the conftitution be healthy, na- 
ture will not probably fail in fupplying 
the deficiency. Thus we have many 
inftances upon record, even of entire 
bones being regenerated ; and, in a le£. 
fer degree, the powers of nature on this 

point 



* Vide White's Cafes in Surgery, where two inftan- 
ces of this are recorded. 



Sect, it on fraftures. 4 % 

point mufl have fallen within the obfer- 
vation of every practitioner. 

A bone is often broke in different parts, 
and a cure notwithstanding obtained : 
but when the detached parts are fo fmall 
that the circulation will not probably be 
kept up in them, as they will thus be ren- 
dered incapable of furnifhing the fecre- 
tion by which their reunion mould be ac- 
complifhed, it would be better to remove 
them at once, than to impede the cure 
by any attempt to fave them. Accord- 
ingly, in all compound fractures, where 
the injured bone is already laid bare, it 
is the practice of our bed furgeons to 
remove all fuch detached portions as 
might not probably unite with the re- 
maining parts of the bone. But in fimple 
fractures, where the lkin remains en- 
tire, as we cannot judge with fuch cer- 
tainty of the nature and extent of the 
injury, nor of the probability of our be- 
ing able to preferve all the loofe por- 
tions of bone, we endeavour in the firft 
place to accompliih a cure in the eafieft 
D a manner.* 



44 General Obfervations Ch. XXXIX. 

manner, by placing the parts in fuch a 
pofitition as will moft readily admit of 
their union being effected : but when 
this does not fucceed, when the ends of 
the bone remain loofe long after they 
mould have been united, and one or 
more detached pieces are difcovered, 
thefe are to be confidered as extraneous 
bodies, and ought to be removed with 
the fingers or forceps, at an opening made 
through the foft parts for this purpofe. 

Experience enables me to recommend 
this method of treatment with confidence. 
I have mer with, different cafes, where 
a cure being confidered as impracti- 
cable from no union having formed be- 
tween the ends of fractured bones, was 
at laft accomplished in the courfe of a 
very fliort time by the removal of fome 
loofe fragments. 

But the moft perplexing caufe prevent- 
ing the reunion of fractured bones, is a 
portion of a mufcle, ligament, or fome 
other foft part paffing between them. 
We judge that this is the cafe when the 

pain 



Sect. I. on FraBures. 45 

pain and tenlion of the injured part have 
been more fevere than ufual from the 
firft ; when particular movements of the 
limb occafion fevere pain and twitchings 
of the mufcles that ferve to move it ; 
and when the ends of the fractured bone 
do not unite at the ufual time. 

As foon as there is any reafon to think 
that a cure is prevented by the caufe 
we have juft mentioned, we mould en- 
deavour to remove the portion of inter- 
pofing membrane or mufcle, by putting 
the limb into all the variety of poftures 
by which it will be moft readily effected. 
But when this does not fucceed, as will 
often be the cafe, and when the bones 
flill remain loofe long after the ufual pe- 
riod, we ought, without farther hefita- 
tion, to make an inchion upon the frac- 
tured part. When the injury has not 
been of long duration, a cure will be 
accomplimed merely by bringing the 
ends of the fractured bone into contact : 
But when this meafure has been too long 
delayed, and when the offeous matter 
D 3 " poured 



46 General Obfervations Ch. XXXIX. 

poured out by the fractured extremities 
of the bone has become hard, a fmall 
portion of it mould be removed either 
by a law or with fome fharp inftrument, 
fo as to convert the injury once more 
into the flate of a recent fracture ; other- 
wife no advantage will be gained by the 
operation. 

Befides thefe caufes I have mentioned, 
which tend to impede the cure of a frac- 
tured bone, it may not be improper to 
remark, that the effufion of much blood 
around the injured bone is very apt to 
be productive of the fame effed. It is 
fffldom, in cafes of Ample fradure, that 
any of the larger blood- veffels are inju- 
red ; and blood effufed from fmall arte- 
ries is for the moft part foon abforbed, 
and no bad effects refult from it. But 
inftances fometimes occur, even in Ample 
fractures, of a large blood -veffel being 
cut by the fharp fpiculse of bone. When 
the quantity of blood thrown out is con- 
fiderable, the tumefaction of the limb 
becomes fo great, that it is neceiTary to 

Jav 



Sect. I. oil FraBures. 47 

lay it open in order to fecure the divi- 
ded vefTel with a ligature : but where 
the fwelling does not arrive at any alarm- 
ing height, we rather truft to the natu- 
ral contractility of the artery for flop- 
ping the hemorrhagy, and to the powers 
of the abforbents* for removing the blood 
already effufed. In fome fuch cafes, 
where blood has remained long in con- 
tact with the extremities of the fractured 
bone, the power of forming callus ap- 
pears to have been deflroyed by it ; the 
periofleum feparates for a corifiderable 
fpace from each end of the bone ; and 
on laying the parts open, no union is 
found to have taken place ; the fpiculx 
produced by the fracture remain -equally 
lharp as at fir ft ; and, for the mofh part, 
a thin fetid fanies is difcharged from the 
fore. 

In this fituation, a cure will not be ob- 
tained till thofe parts of the bone which 
have been denuded of the periofleum 
have exfoliated. As exfoliation is in ge- 
neral a tedious procefs, we wotild rather 
advife the removal of the denuded bone 
D 4 -by 



4& Of Frafiures Ch.XXXIX. 

by means of a faw. A more expeditious 
and more certain cure will thus be ob- 
tained. 

Having premifed thefe general obfer- 
vations, we proceed to the confideration 
of fractures in particular parts. 



SECTION n. 

Of FraElures of the Nofe, 



TH E arch formed by the bones of 
the nofe prevents them from being 
fo frequently fractured as they otherwife 
would be. They are neceflarily, how- 
ever, liable to every variety of fracture 
when expofed to any great degree of 
violence. 

Befides the ufual fymptoms of fradures, 
injuries of this kind in the bones of the 
nofe are apt to impede refpiration ; they 

affect 



Sea. II. of the Nofe. 49 

affect the fpeech and the fenfe of fmelling ; 
polypi and tedious ulcers fometimes enfue 
from them ; and they are rendered more 
particularly hazardous from their conti- 
guity to the brain. Thefe fractures there- 
fore require the moft exact attention. 

When we have afcertained the nature 
and extent of the fracture, our next object 
is to replace the bones as nearly as pof- 
fible in their natural fituation. When 
any part of them has been elevated or 
raifed above the level of the reft, it muft 
be preffed into its fituation with the fin- 
gers \ while fuch parts of them as may 
have been forced into either of the no- 
flrils muft be elevated with the end of a 
narrow fpatula, or any other inftrument 
of a fimilar form. Any portion of bone 
that is quite loofe, and nearly fcparated 
from the reft, fhould be removed imme- 
diately, whether it be raifed up or forced 
into the noftril ; but whatever adheres to 
the remaining portion of bone with much 
firmnefs, fhould be replaced in the man- 
ner we have mentioned. 

If 



co Of FraBures Ch. XXXIX, 

If the bones be properly replaced, they 
will for the moft part remain in their 
iituation without any affiftance. If there 
is a wound, it muft be dreffed in the 
ufual way ; and whether the teguments 
be injured or not, we mould endeavour to 
prevent inflammation by the ufe of fatur- 
nine applications, and by local blood- 
letting when the violence of fymptoms 
renders it neceflary. 

But when the parts that have been 
replaced do not remain firm in their 
iituation, we are under the neceflity of 
endeavouring to retain them. If they 
fall into the noftrils, the beft method 
of effecting this is to introduce fuch 
tubes into them as are reprefented in 
Plate XLIII.fig.2. If the tubes are cover- 
ed with foft lint, fpread with any emol- 
lient ointment, they may be kept in the 
noftrils as long as may be necefTary : 
While, on the contrary, if any part of 
the bone is raifed above the reft, it muft 
be kept down by a proper application of 
3 double-headed roller. If the tegu- 
ments 



Sea. II. oftheNofe. $\ 

merits are injured, the fore muft be flrft 
drelTed ; care being taken in doing it to 
prevent deformity as much as poflible : 
a comprefs of foft old linen muft be next 
applied ; and over the whole an equal 
prefTure muft be made by the bandage 
we have juft mentioned. 

In this manner a cure may be obtain-" 
ed of almoft every injury of this kind, 
unlefs the bones have been fo much fhat- 
tered, that their reunion cannot be ac- 
complifhed. In which event, all that 
art can do is to extract the detached 
pieces, and to co-operate as much as 
poflible with nature in healing the re- 
maining fore. 



SECTION 



5* °f Fr a aures °f the CLXXXIX. 

SECTION IIL 

Of Fraclures of the Bones of the Face. 



WHEN treating of fra&ures of the 
fkull, thofe of the upper part of 
the face were confidered. At prefent we 
have only a few obfervations to offer on 
fractures of the fuperior maxillary and 
cheek-bones, being thofe which form the 
moft prominent parts of the fides of the 
face. 

The vicinity of thofe bones to the 
eyes and to the nofe, and the fituation 
of the antrum maxillare, make fractures 
of thefe important. When the fractures 
ftretch toward the eyes, they are apt to 
induce much inflammation, which often 
proves dangerous ; and when they pene- 
trate the antrum, they not only prove 
extremely tedious, but very commonly 
©ccafion a good deal of deformity: for 

when 



Sect. III. Bones of the Tacr. 53 

when the anterior part of that cavity is 
laid open, and any portion of the bone 
removed, the face becomes flat, and the 
teguments puckered, notwithstanding all 
that can be done to prevent it. 

In every injury therefore of this kind, 
we ought to be careful in replacing any 
portion of bone that may be fractured, 
fo as to favour its reunion with the reft ; 
and any wound that accompanies the 
fracture fliould be dreffed with much at- 
tention, that deformity, as far as it is 
poflible, may be prevented. 

After the bones are replaced, which 
may be .done "either with the fingers 
where there is no wound, or with for- 
ceps or a narrow fpatula when the parts 
are laid open, a piece of adhefive plafter 
will anfwer better than any bandage for 
retaining the neceflary dreflings. Blood- 
letting and an antiphlogiftic regimen muft 
be advifed to obviate inflammation of 
the eye or contiguous parts, which other- 
wife might enfue. The remaining part 
of die cure, namely, the reunion of the 

fractured 



54 OfFraftures of the Ch. XXXDC 

fractured parts of the bone, muft be left 
entirely to nature. 

When the fracture penetrates the an- 
trum, the matter which collects in that 
cavity cannot be properly evacuated from 
any opening that may take place on the 
prominent part of the cheek. In confe- 
quence of this, I have known finuous 
ulcers formed that have continued open 
for a great number of years. They can 
only be healed by giving a free vent to 
the matter, by an opening made in the 
moft depending part of the cavity, in the 
manner we have advifed in Chap. XXX. 
Section V. • 



SECTION IV. 



Of Fraclures of the inferior Maxillary Bones. 



ALthough the bones of the under 
jaws are very ftrong and compact:, 
yet fractures of one, or even of both, are 

not 



Sect. IV. inferior Maxillary Bones'. 55 

not unfrequent. This feems to arife 
from blows or other injuries to which 
thefe bones are expofed, being molt apt 
to fall upon their anterior flat furfaces, 
where they are lefs capable of refilling 
violence than in any other part. 

We judge of the exiftence of a frac- 
ture in the jaw, by the deformity which 
it occafions ; by the crackling of the 
bone when handled ; by inability to 
move the jaw ; by the violence of the 
injury, and the degree of pain with which 
it is accompanied. — When both jaws are 
broke, the injury becomes obvious ; as 
in this cafe a confiderable feparation 
takes place at the fractured part : but 
even where one bone only is fractured, 
it may be always difcovered with a little 
attention. 

The fite of the fracture being exactly 
afcertained, our next object is to replace 
the bones with as much care as pomble : 
which is done by placing the patient in 
a proper light, having his head firmly 
fecured, and the fingers of one hand 

prefling 



56 Of FraSiures of the Ch. XXXIX. 

prefling upon the infide of the jaw, 
while the other hand is employed exter- 
nally in guarding againft any percep- 
tible inequality of the bone. One of 
the teeth is commonly feated in the 
courfe of the fracture ; and in this fitu- 
ation acting as an extraneous body, and 
thus tending to retard the cure, it Ihould 
be a general rule to extract: it immedi- 
ately : But when any of the teeth not 
feated in the courfe of the fracture, are 
forced out of their fockets, it may be 
right almofl in every inftance to replace 
them, and to endeavour to fix them, by 
tying them to the contiguous firm teeth. 
This being done, our next object is to 
retain the fractured bones in a proper 
fituation till they are firmly reunited. 
For this purpofe a variety of fplints have 
been invented, both of pafteboard and 
other materials ; but as a comprefs and 
bandage either of foft old linen or cot- 
ton anfwers the purpofe with equal cer- 
tainty, and as they fit with much more 
eafe to the patient, they fhould always 
2 be 



Sect. IV. inferior Maxillary Bones. 57 

be preferred. The parts being kept firm 
by an afliftarit, a thick comprefs fliould 
be laid over the chin, and be made to 
extend from ear to ear along each jaw ; 
and over the whole a four-headed rol- 
ler mould be applied in the manner we 
fhall mention when treating of bandages. 
In riling this - bandage, it fhould not be 
made fo tight as to give much uneafi- 
nefs, or to endanger the circulation, at 
the fame time that it fhould be applied 
in fuch a manner as to keep the fractu- 
red parts of the bone in clofe contact. 

During the cure the patient fhould 
be kept perfectly quiet. He fhould be 
fed entirely on fpoon-meat. He fhould 
be enjoined to avoid fpeaking and laugh- 
ter, or the ufe of his jaws in any manner 
of way. To prevent the difplacement 
of the bones, which is apt to happen from 
frequent inflection, the bandage fhould 
be applied with flich attention, that there 
may be no.occafion to move it oftener 
than is altogether neceffary. In com- 
pound fractures of this part, there is in- 
Vol. VI. E deed 



5§ Of FraBuns of the Ch. XXXIX. 

deed a neceffity for moving the bandage 
daily, as the fore cannot otherwife be re- 
gularly dreiTed. It ought always to be 
done, however, with the utmoft atten- 
tion, an amftant taking care to fupport 
the parts with his hands during the re- 
moval of the old, and the application of 
the new drerlings. 

The management of a fracture of one 
or both jaw-bones is exactly fimilar ; 
only where both bones are broke, there 
is Hill more attention required than 
when one only is fractured. In a frac- 
ture of one of the bones, the patient may 
be allowed to eat foft meats, and to fpeak 
with freedom, in the fpace of three 
weeks : But where both bones have fuf- 
fered, this mould not be permitted till 
the conclusion of the fifth week. 



SECTION 



Sect. V, Clavicles and Ribs. 59 



SECTION V. 



Of Fractures of the Clavicles and Ribs. 



r T"HE clavicles arid ribs are more liable 
to fractures than any other bones. 
This proceeds not only from the flender 
ftructure of thefe bones, but from the 
tranfverfe pofition in which they are 
placed, with their flat broad-fides expo- 
fed to every injury that may be applied 
to them. 

A fracture of the clavicle is in gene- 
ral eafily diftinguifhed. A grating noife 
is produced by the ends of the bone rub- 
bing againft each other, on the arm of 
the fame fide being fmartly moved* The 
ends of the fractured part readily yield 
to preffure ; and, for the moll part, the 
end of the bone connected with the hu- 
merus, is pulled to fome diftance from 
E 2 the 



6a O/FraSiurcs of the Ch. XXXT3C 

the other by the weight of the arm. 
The motion of the humerus- is impeded,, 
and fome degree of fwelling, accompa- 
nied with more or lefs pain, takes place 
over the injured part. 

In examining a fractured clavicle, we 
almoft always find the end connected 
with the ftercmm higher than the other, 
which has fuggefted an idea that has pre- 
vailed very univerfally in the method of 
cure. It is fuppofed that the height of 
this part of the bone proceeds from its 
having ftarted or rifen out of its natural 
fituation : In the reduction, therefore, 
of the fracture, a good deal of pains is: 
commonly taken to prefs it down, and 
very tight bandages, are employed to pre- 
vent it from rifing -during the cure. I 
believe, however, it will be found, that 
this part of the bone rifes very little out 
of its natural fituation, and that the ap- 
pearance of its doing fo proceeds almoft 
entirely from the other end of the bone 
being dragged downwards by the caufe 
we have mentioned, namely, by the 
weight of the arm. At any rate, no 

advan- 



Sea. V. Clavicles and Ribs, i 61 

advantage is obtained from this practice : 
for a force that would be neceflary for 
prefling down the end of the bone, cannot 
be applied without the effect of cutting the 
teguments, by preffmg them againfl that 
part of it which is fiippofed to be ele- 
vated; while our purpoie is fully an- 
iwered by railing the arm, and {import- 
ing it at a proper height. The de- 
preffed portion of the fractured cla- 
vicle is thus raifed and brought into 
contact with the fuperior part. In fome 
cafes, indeed, of very oblique fractures, 
it may be impomble to bring the ends of 
the bone in every point exactly oppofite 
to each other : but tfhis may be always 
fo far accompiifhed as to enable us to 
avoid deformity, and to render the bone 
fufficiently ftrong. 

When the ends of the bcfie are brought 
into contact, our object is to retain them 
in this fituation till they are united ; 
and, as we have obferved above, this can 
only be done by affording a proper fup- 
port to the arm. 

The arm is ufually fupported by a 
E 3 fling 



62 OflraBures of the Gh. XXXIX. 

fling hiing round the neck, adapted to 
the length of the arm, and every where 
equally applied to it. But the leather 
cafe reprefented in Plate LXXXI. fig. I. 
anfwers this purpcfe with more eale and 
neatnefs. By means of it the fore-arm 
and elbow-joint are more equally and 
more effectually fupported : and this laft 
is a point of no fmall importance ; for 
if the elbow be allowed to drop, the hu- 
merus and fcapula will both fall down, 
by which the ends of the fractured cla- 
vicle will again be feparated. 

We are commonly directed in the treat- 
ment of fractures of this bone to have 
the moulders drawn back and the head 
raifed ; and inftruments are defcribed 
for effecting thefe purpofes. No gene- 
ral rule, however, of this kind can be 
laid down : %>r in fome cafes we find 
that the fractured parts of the bone are 
kept mofl exactly together when the 
head is bent down upon the breaft ; 
while in others, it is better accomplished 
while the head and moulders are raifed. 

In ether points, fractures of the cla- 
vicle, 



Sed. V. Clavicles and Ribs. 63 

vicle mu(t be treated like fimilar injuries 
in other parts of the body. When there 
is much pain and fwelling, bleeding with 
leeches becomes proper ; but in general, 
injuries of this kind are fo flight, that the 
-common faturnine applications prove fuf- 
ficient for removing any inflammation 
or fwelling that occur. When the frac- 
ture is accompanied with a wound, any 
fplinters of bone that may be difcovered 
muft be removed, and the wound itfelf 
drefTed in the ufual way. It is proper, 
however, to remark, from the vicinity of 
the fubclavian artery, that the removal 
of any portion of the clavicle muft be 
attended with danger, and ought there- 
fore to be managed with caution. 

When the ends of the fraclured part 
are fupported with exactnefs, they will 
in general be firmly united * in the fpace 
of a fortnight ; but the correfponding 
arm fhould never be ufed with freedom 
till the end of the third or fourth week. 

We difcover fractures of the ribs by 

the feat of the pain, and by prefiure with 

E 4 the 



64 OfFraBures of the Ch. XXXIX. 

the fingers. For the mod part, the Symp- 
toms which take place are moderate ; the 
pain induced by the fracture is inconfi- 
derable, no fever occurs, and the patient 
foon gets well : But in fome inffcancek 
the pain is fevere from the firfl ; the 
breathing becomes difficult, attended 
with cough, and perhaps a fpitting of 
blood ; and the pulfe is quick, full, and 
fometimes oppreffed. 

It will readily be underftood, that a 
fractured rib cannot of itfelf induce any 
of thefe fymptoms : But in fome in- 
fhances the ribs are not only fractured, 
but pufhed inwards upon the pleura and 
lungs ; when, from the compreffio'n and 
laceration of thefe parts, we may eafily 
perceive how pain, oppreffion in breath- 
ing, and fever, mould be induced ; and 
at the fame time be able to account for 
the emphyfematous fwellings defcribed 
in Chapter XXII. Section V. 

In every cafe of fracture of the ribs, 
it is a fafe and proper practice to dif- 
charge a quantity of blood proportioned 

to 



Sect V. Clavicles and Ribs. 65 

to the ftrcngth of the patient. If any 
inequality is difcovered, by one end of 
the rib having rifen above the other, we 
ought to endeavour by moderate equal 
prelTure to replace it ; and to prevent it 
from riling, a broad leather belt mould 
be applied, and drawn as tight as the pa- 
tient can cafily bear it. When a belt of 
this kind is properly lined, either with 
quilted cotton or flannel, it fits with eafe 
even when tolerably tight ; and it ought 
to be continued for feveral weeks after 
the accident. 

Even where the fymptoms have at 
nrft been fevere, they will commonly 
iubfide upon the patient being freely 
blooded and kept quiet and on a low re \ 
gimen : But where the opprefled breath- 
ing is kept up by air efcaping from a 
puncture in the furface of the lungs, or 
by blood difcharged from a ruptured in- 
tercoftal artery into the cavity of the 
cheft, or when the pain is prevented, from 
fubfiding by the fractured rib being for T 
ced in upon the pleura ; it becomes necef- 

fary 



66 Of FraStures Ch. XXXIX. 

fary to make an opening with a fcalpel. 
Where a portion of rib is merely forced 
inwards, this fliould be done directly up- 
on the injured part ; and on the rib be- 
ing laid bare, we ought to elevate that 
part of it that is deprefTed, either with 
the fingers, forceps, or a fpatula. When 
the fymptoms proceed from air or blood 
collected in the cavity of the cheft, an 
opening fhould be made to difcharge 
them, in the manner pointed out in Chap- 
ter XXII. Seftions III. and V. 

Fractures of the ribs fhould in every 
inftance be treated with attention ; but 
particularly where there is any tendency 
to phthifis pulmonalis, when the irrita- 
tion produced by a fractured rib is very 
apt to do mifchief. 



SECTION 



SeSi. VI. ef the Sternum. 



SECTION VI. 

Of Fraftures of the Sternum. 



TH E fupport which the fternum re- 
ceives from the ribs, and the de- 
gree of elafticity which it poffeffes, ren- 
der it lefs liable than it otherwife would 
be to injury from external violence. It 
neceflarily fuffers, however, from the 
application of any great degree of force. 
In fome cafes, it is fractured without be- 
ing difplaced : in others, it is not only 
broke, but at the fame time beat in up- 
on the pleura. 

A fimple fracture of the fternum is to 
be confidered in the fame light with fi- 
milar injuries done to the ribs, and ought 
to be treated in the fame manner. But 
more danger is apt to enfue from any 

portion 



6S Of Fractures Ch. XXXIX. 

portion of this bone being forced into 
the cheft from the vicinity of the large 
blood-velTels of the breaft, while the 
lymptoms with which it is accompanied 
are nearly the fame ; namely, pain in the 
injured part, 'cough, oppreffed breathing, 
a quick and fometimes an oppreffed pulfe. 

In flight affections of this kind, we 
are told, that the depreffed portion of 
bone may be raifed by defiring the pa- 
tient to make deep infpirations ; by pla- 
cing a barrel or a drum under his back, 
and keeping him lying for fome time in 
this poflure ; and by the application of ad- 
hefive plafter over the correfponding te- 
guments ; when, by elevating the foft 
parts, the bone beneath, it is faid, may 
frequently be raifed along with them. 

It is not to be fuppofed, however, that 
any advantage is to be derived from any 
of . thefe methods ; on the contrary, it 
is more likely that they may do harm : 
nor would they have been mentioned 
here, had it not been with a view to cau- 
tion the younger part of the profeffion, 

who. 



Sed. VI. of the Sternum. 69. 

who, finding thefe modes of practice re- 
commended by all the older writers, 
might have been induced to adopt them 
without weighing their confequences. 
As the fkin is no where very intimately 
connected with the bone beneath, it is 
not probable that any portion of depref- 
fed bone will ever be railed by the ex- 
ternal application of adhefive plaflers ; 
and we may do harm by trufting to a 
mode of treatment that is to prove inef- 
fectual. But the practice of adviiing 
deep infpirations, and of laying the pa- 
tient upon his back over a large barrel 
or any other convex body, muft often da 
mifchief, by pufhing the lungs with more 
force againft the depreiled portion of 
bone than they otherwife would be. 

When it therefore happens that the 
pain, cough, opprefled breathing, and 
other fymptoms, do not yield to blood- 
letting and other parts of an antiphlo- 
giflic courfe, fome other method of 
cure mould be attempted. An incifion 
fhould be made upon the injured part, 

of 



yo Of FraBures of the Ch. XXXIX; 

of a fufficient length to admit of a free 
examination of the bone ; when the de- 
prefTed piece may be raifed either with 
a common fcalpel or a levator, if there 
be an opening that will admit an inflru- 
ment ; or when this is not practicable, 
an opening may be made for this pur- 
pofe with the trepan, in the manner we 
have advifed in fimilar injuries done to 
die fkull in Chapter XXVI. 

I know that this will be confidered by 
many as hazardous ; but when a patient 
is in danger either from a portion of a 
depreffed rib or of the fternum, and 
which cannot otherwife be raifed, I 
would never hefitate in advifing it. If 
the operation be performed with caution, 
the bone may be raifed with fafety ; and 
this being done, the fore muft be treated 
in the ufual way. 



SECTION 



Sect. VII. Vertebra, Os Sacrum, zyc. 71 



SECTION VII. 



Of Fractures of the Vertebra?, Os Sacrum^ 
Coccyx, and OJJa Innominata. 



FRactures of the vertebrae may be 
produced by falls and blows ; but 
they are more frequently the confequen- 
ces of gun-fhot wounds than of any other 
caufe. 

Injuries of this kind, for the moft part, 
terminate fatally : for although many 
have furvived fuch fractures for a confi- 
derable time, yet they generally linger 
and die of the confequences. The fpi- 
nous and oblique proceffes of the ver- 
tebra* may indeed be broke without im- 
mediate danger ; but very commonly the 
force which effects this, gives fuch a fhock 
to the fpinal marrow, as at laft termi- 
nates 



72 Of Fradurcs of the Ch.XXXIX: 

nates in the death of the patient : and a' 
fracture extending through the body of 
a vertebra will probably, in every in- 
ftance, prove fatal. 

We judge that the vertebras are frac- 
tured, by the feel, by the violence of the 
injury, and the feverity of the pain, and 
by the parts lying beneath the injured 
vertebra becoming paralytic when the 
fpinal marrow is affected. * 

When any of the external parts of 
the vertebrse are loofe, we may in gene- 
ral replace them with our fingers ; and 
confining the patient as much as pof- 
fible to one pofture, we may, by means 
of the napkin and fcapulary bandage, 
and proper comprefles, retain them in 
their fituation till they unite with the 
reft of the bone. 

Where this cannot be done, a patient 
is in general left to his fate, as it is not 
luppofed that we can with propriety ex- 
pofe any of the vertebras for the pur- 
pofe of replacing fuch parts of them 
as may be deranged : But wherever we 

find 



'Sect. VII. Vertebrt, Os Sacrum, &c. 73 

find that the fpinal marrow is compref- 
fed, as the immediate effect of an injury 
done to one or more of the vertebra? ; 
and where there is reafon to think that 
the compreflion is produced by a frac- 
ture and depremon of a portion of bone, 
as we know from experience that every 
fuch cafe will terminate fatally if the 
caufe of compreflion be not removed, it 
would fuYely be better to endeavour to 
raife it than to leave the patient under 
an abfolute certainty of fuffering. By 
laying the injured parts freely open, we 
may be enabled to raife that portion of 
bone by which the compreflion is produ- 
ced ; while it is not poflible that the fi- 
tuation of the patient can be rendered 
more hazardous, even allowing the at- 
tempt to prove abortive. 

In a cafe where fymptoms of paralyfis 
were induced by a mufket-bullet lodged 
in the fubflance of one of the vertebras, 
a complete recovery was obtained by ex- 
trading the bullet. A portion of de- 
preffed bone might in many inftances be 

Vol. VI. F removed 



74 Of Fractures of the Ch.XXXIX. 

removed with equal eafe and fafety ; and 
we have reafon to fuppofe that fimilar 
effects would often refult from it. 

In fractures of the os facrum, the me- 
thod of treatment muft be nearly fimi- 
lar to what we have juft advifed in frac- 
tures of the vertebrae ; only, where the 
injury is feated near to the under part 
of the bone, as well as in fractures of 
the coccyx, when any part of it is pref- 
fed inward, we may in fome cafes be 
able to replace it, by pufhing it out with 
the finger of one hand introduced into the 
anus, while with the other we co-operate 
externally. 

Where any of the ofla innominata are 
broke, iCthe injury be deeply feated, the 
patient ought to be placed in that pofture 
in which he finds himfelf eafieft, and 
confined as much as poffible to that fitu- 
ation till it is probable the bones may 
be united. Blood-letting, and an atten- 
tive regimen, fuited to his ftrength and 
£he violence of the fymptoms, may pre- 
vent 



Sect. VII. Vertelr^ Os Sacrum, f$c. 75 

vent the inflammation which uftially fu- 
pervenes from becoming confiderable. 

In more external fractures of thefe 
bones, we have it often in our power to 
replace fuch parts of them as have been 
forced out of their natural fituation ; and 
by a proper application of bandages, we 
may aho be able to retain them till a 
cure is completed. I have had different; 
inftances of a confiderable portion of the 
ileum being fractured and feparated from 
the reft, and of a cure being eafily ac- 
complished, by replacing the parts that 
were feparated, and retaining them with 
a broad roller palled feveral times round 
the pelvis and upper part of the thigh. 

With refpect to the application of fuch 
a bandage, no general directions can be 
given: It muft depend entirely on the 
judgment of the practitioner j who will 
apply it in the way which he thinks wil I 
make it anfwer the purpofe of fixing the 
bones in the moil effectual manner. 

F 2 SECTION 



7$ Of FraBures Ch. XXXIX, 



SECTION VIII. 



Of Fraclures of the Scapula. 



HP HE fcapula, from its fituation, is not 
fo liable to be fractured as other 
bones ; but every practitioner mull have 
met with inftances of this accident. It 
may be fractured either in the thin plate, 
of which it is moftly formed ; or in one 
or other of its proceiTes. 

As the motion of the arm depends 
much on a found and entire flate of this 
bone, and as fractures of any part of it 
are difficult to cure, they very commonly 
produce a ftifF unwieldy flate of the cor- 
refponding arm, which ufually continues 
(during the life of the patient. 

We d if cover that the fcapula is frac T 
Sured, by the feat of the pain ; by the 

violence 



Sed. VIII. of the Scapula, jj 

violence of the injury ; by the feeling on 
prefling the injured parts ; and by ftifF- 
-nefs and immobility in the correfpond- 
ing arm. We are told, that fractures of 
the fcapula are apt to be accompanied 
with emphyfematous fwellings. Thefe 
can only appear when the lungs are 
wounded by a fplinter of the fcapula, or 
of a fractured rib being forced into their 
fubftance. When this takes place, air 
will no doubt efcape ; and if it paffes in- 
to the cellular fubftance, emphyfematous 
fwellings will neceflfarily occur. 

In the treatment of fractures of the' 
fcapula, our firft object is to replace the 
bones with as much exactnefs as poflible ; 
and in doing fo, we will be much afhft- 
ed by relaxing all the mufcles connected 
with the injured part. By raifing«"the 
head and fhoulders we relax the mufcles 
of the back ; and if, at the fame time, 
the humerus be fupported, the deltoid 
mufcle will be fo much relaxed, that any 
fractured portion of the fcapula may be 
eanly replaced. There is more difficult 

f 3 ni 



7$ OfTraElures Cn. XXXtX. 

ty, however, in retaining the bones du- 
ring the cure, than in replacing them : 
for the detached portion being in gene- 
ral fmall, it is often impoffible to retain 
it with a bandage, A proper application 
of a long roller is perhaps the only me- 
thod by which it can be done ; and in 
nfing this bandage, we fhould frill take" 
care to have the head and moulders flip- 
ported, and the arm' fulpended, fo as to* 
keep alt the mufcles of the injured part 
as much relaxed as poffible. 

As fractures in every part are apt to* 
excite inflammation, we have eMewhere 
obfervedV that this fymptom mould at all 
times Be guarded agamft. It is no where, 
however, more neceflary to be attentive 
to this than m fractures of the fcapula, 
wherr inflammation is more apt to pro- 
ceed to an alarming height than in any 
other part. Blood-letting fhould there- 
fore be freely practifed ; particularly, lo- 
cal blood-letting with leeches, or cup- 
ping and fcarifying ; which we have of- 
ten had occafion to recommend as per- 
haps 



Sect. IX. ' of the Humerus, 79 

haps the moft effectual means of remo- 
ving inflammation wherever it may be 
feated. 



SECTION IX. 

Of ' Fraftures of the Humerus. 



AS the humerus is not thickly cover- 
ed with foft parts, any fractures to 
which it is liable are, in general, eafily 
difcovered. When they run obliquely, 
they become often evident to the fight ; 
as in that cafe the bones are apt to over- 
lay one another : but we have feldom 
any difficulty in difcovering even tranf- 
verfe fractures ; which we do by the feat 
of the pain, the violence of the injury, 
inability to move the injured arm, and 
a grating noife being heard on handling 
the parts affected. 

F 4 In 



£o OfFraBures Ch.'XXXIX* 

In reducing fractures of this bone, we 
do not find that much extenfion is necef- 
fary ; but in order to accomplifh it with 
eafe, the mufcles of the arm fhould be 
put as much as poflible into a flate of 
relaxation ; which is done by bending 
the elbow moderately, at the fame time 
that the limb is raifed nearly to a hori- 
zontal direction, and not carried fo far 
forward as to put the latimmus dorli, in- 
ferted into the back part of it, on the 
ftretch, or too far back to ftretch the 
pectoral mufcle.. 

The patient being properly placed, and 
trie arm, put into this fituation, the fur- 
geon will in general be able to replace the 
bones without any amftance : But when 
extenfion is necelfary, it may be applied 
by one affiftant grafping the arm between 
the fracture and the joint of the moul- 
der, and another above the joint of the 
elbow. 

In this manner the fractured bones are 
to be exactly replaced ; and with a view 
to fecure them in this fituation, one fplint, 

of 



Seel. IX. of the Humerus'. 81 

• of a proper degree of firmnefs, fuch as are 
reprefented in plate LXX. fig. 5. and 6. 
fhould be laid along the whole outfide 
of the arm, and another along the infide 
of it, each of them covered with foft 
thin flannel, to prevent them from gal- 
ling the arm ; and while thefe are fecu- 
red by one ailiftant, and the fore-arm 
fupported- by another, a flannel roller 
fhould be applied over the whole, of fuch 
tightnefs as to fupport the ends of the 
fractured bone without interrupting Kbe 
circulation of the limb. 

The fore- arm fhould be fupported in 
a fling, fuch as is reprefented in Plate 
LXXXI. fig. 1. and the patient maybe 
either put to bed or allowed to fit, as is 
molt agreeable to himfelf. It may not, 
however, be improper to remark, that it 
anfwers better to have the arm in a hang- 
ing pofition than laid horizontally upon 
a pillow ; particularly in oblique frac- 
tures of this bone, where the weight of 
the limb has a confiderable effect in pre- 
venting the ends of the bone from over- 
• - lapping 



8z Of Fradurii <Jh. XXXIX; 

lapping each other. Even in bed, there- 
fore, where there is any. danger of this" 
taking place, the patient fhould be pla- 
ced in fuch a manner, that his arm may 
hang inftead of being laid in the ufual 
pofture. In tranfverfe fractures this pre- 
caution is not altogether fo necefTary, as 
the ends of the bone, if they be once 
properly replaced, ferve effectually to 
fupport each other. But even in thefe, 
it is the beft practice to fupport the fore- 
arfti in fuch a manner that it may have 
fome effect in pulling the under part of 
the humerus gently downwards. 

If no urgent fymptom occurs* fuch as 
mudh pain and fwelling of the arm, the 
bandage fliould not be moved for feveral 
days: But about the feventh or eighth 
day, it is proper, in every fracture, to* 
remove all the coverings, in order to fee 
whether the bone be perfectly in its place 
or not ; for at this period any acciden- 
tal difplacement may be eafily put right, 
and a cautious infpection may be made 
with the utmoft fafety. 

• We 



Sect. IX. of the Humerus] 8# 

We have advifed a roller to be employ- 
ed for fractures of this bone ; and per- 
haps it is the only inftance in fractures 
of the large bones of the extremities in 
which it mould be preferred to the many- 
tailed bandage. But whoever has ufed 
them both will find, that in fimple frac- 
tures of the humerus, the roller is not 
only more eafily applied than the other, 
but that it anfwers the purpofe better. 

Fractures of the humerus commonly 
heal more kindly than fimilar injuries 
of any other part ; and ' when properly 
managed, they feldom leave either lame- 
nefs or diftortion of the arm. When no 
interruption occurs to the cure, either 
from fevere pain, fwelling, or inflam- 
mation, or from accident or mifmanage- 
ment, the bone will in generaUbe firmly 
united in lefs than a month; but the 
limb fhould not be ufed with much free- 
dom till the ftxth or feventh week. 



SECTION 



&4 Of Fra&urcs of the Ch. XXXIX. 



SECTION X. 



Of Fractures of the Bones of the Fore- Arm. 



THE bones compofing the fore-arm 
are two in number, the radius and 
ulna. From their being much expofed 
to accidents, they are very liable to frac- 
tures. When both bones are broke, the 
nature and feat of the injury are for the 
mod part eafily difcovered ; but when 
one bone only is fractured, efpecially if 
it be the radius or fmaller bone, as the 
firmnefs df the other prevents it from 
being difplaced, it requires fome atten- 
tion to difcover it. The feat of the pain 
points out the injured part ; and when, 
either of the bones is fractured, a gra- 
ting noife will be heard if the furgeon 
grafps the limb firmly above and below 

this 



Sect, X. Bones of the Fore-Arm. 8^ 

this part, and endeavours to move it in 
different directions. 

In this examination, it is of much im- 
portance to diftinguifh the direction of 
the fracture with as much exactnefs as 
pomble, particularly if it be near to 
the wrift ; for upon this the chance of 
our making a proper cure in a great 
meafure depends : and in this fituation, 
whether both bones or only one of them 
be broke, the utmoft nicety is required 
to prevent a ftiff uneafy ftate of the arm 
from continuing long after the fracture 
is healed. It is not unfrequent, indeed, 
to hear patients complain of this incon- 
venience after thefe fractures, during the 
remainder of their lives ; and I think it 
is more apt to happen when the radius 
is broke by itfelf than when the ulna on- 
ly is fractured, owing to this bone ha- 
ving a rotatory motion independent of 
the other, by which it is with more diffi- 
culty kept in its fituation, And as there 
is nothing for which practitioners are 
more apt to be blamed than for thofe in- 
conveniences 



86 O/Fraaures of the Ch. £XXIX. 

conveniences which patients fuffer after 
the cure of fractures, we ought, in every 
cafe of this kind, to treat it with the ut- 
moil attention. 

After difcovering the feat of the inju- 
ry, if any part of either of the bones be 
difplaced, we ought, as foon as it can be 
done with propriety, to put it right. 
The patient being properly feated, and 
the mufcles of the arm relaxed by bend- 
ing the joints of the wrift and elbow, 
the limb mould be extended to fuch a 
degree, by one amftant grafping it above 
the fracture, and another beneath it, as 
is juft fufficient to allow the furgeon to 
replace the Jbones with exactnefs. This 
being done, one of the fplints reprefent- 
ed in Plate LXX. fig, 3. 4, or 5. cover- 
ed with foft flannel, and of a length to 
reach from the elbow to the tops of the 
fingers, and of fuch a breadth as to inr 
cafe rather more than one half of the 
arm and hand, mould be placed along 
the ulna. Another fplint not quite 1q 
broad muft be placed along the courfe 

of 



V 



tTiATW. r,\X. 



ITiax. 




Fie. 4 






Flg. 6. 


J?XG. 3. 

km l 




i ,i i i ' 


Tik 


Ir!' 1 il 


in ; !' ! 'i' 

If';/ 



Sect. X. Bones of the Fore-drm. 87 

of the radius ; when both may be fecu- 
red either with a flannel roller or a 
twelve-tailed bandage, of fuch a degree 
of tightnefs as to prevent the bones from 
flipping out of their place, but without 
impeding the circulation, or giving the 
patient any uneafinefs. The laft men- 
tioned bandage anfwers the purpofe ex- 
tremely well ; but the roller may be ufed 
in all Ample fractures of thefe bones with- 
out any impropriety. 

In applying the fplints, the palm of 
the hand {hould be turned towards the 
breaft, as being not only the moft con- 
venient pofture in which the arm car* 
hang while in a fling, but as being the 
beft in which it can at all times be pla- 
ced,, even when the patient is, in bed : 
for the palm of the hand can neither be 
turned upwards nor downwards ; that is, 
it can neither be put into a prone nor a 
fupine pofture, without giving that rota- 
tory motion to the radius which- tore have 
mentioned, and which tends more than 
any other to difplace any part of this 

■ bone 



88 OfFraSures of the Ch. XXXIX. 

bone that is fractured. It ought, there- 
fore, to be carefully guarded againft ; 
and I know of no method by which it 
can be done with fuch certainty as fecu- 
ring the arm with fplints in the way we 
have pointed out. It mud now be hung 
in the fling reprefented in Plate LXXXI. 
fig. i. and allowed to remain in the lea- 
ther cafe during the night, or in any 
fmall box of a fimilar conftrudlion, and 
of a fize juft fumcient to receive the arm 
when placed upon its fide, but without 
admitting of its turning either one way 
or another. 

. In fpeaking of the fplints, I have ad- 
vifed them to be of a fumcient length 
for ftretching along the whole courfe 
of the arm from the elbow to the top 
of the fingers. The under one ought 
more efpecially to be of this length : 
for the arm not only refls with more 
eafe and equality upon a long fplint, but 
k ferves »to cover the fingers, by which 
they are prevented more effectually than 
in any other manner from moving; a 

cir- 



Sect. IX. Bones of the Fore-Arm. 89 

circumflance of much importance in. all 
fractures of the fore-arm : for when a 
free motion of the fingers is permitted, 
it not only tends to keep up inflamma- 
tion and pain, but is often the caufe of 
the bones being again difplaced, when 
otherwife they might have been kept in 
contact. 

A partial diflocation of the bones form- 
ing the joint of the wrift, is not an un- 
frequent concomitant of a fracture of 
the radilis ; by which the rifk of a flifF 
joint, or of a painful permanent fwelling 
of the arm becomes confiderable. In 
fuch circumftances, it is therefore always 
proper to inform the patient of his dan- 
ger : for even under the belt manage- 
ment, a diflocation of the wrift, and a 
fracture of the contiguous bone, are apt 
to be productive of this effect. For the 
method of reducing the diflocation, we 
muft refer to the enfuing chapter ; and 
we have already pointed out, in the firft 
fection of this chapter, the moil effectual 
method with which we are acouainted, 

Vol. VI. G of 



$o OfFraStwres of the Ch. XXXIX. 

of preventing and removing inflamma- 
tion ; which we have there fhewn to be 
the moft frequent caufe of that ftrff im- 
moveable ftate in which fractured limbs 
are often left. 

The olecranon, or upper end of the 
ulna, is fometimes fractured without any 
injury being done to the reft or the bone \ 
this part of the bone being particularly 
apt to fuffer from falls and bruifes upon 
the elbow. 

In this cafe, in order to keep the frac- 
tured parts in contact, the fore-arm mufl 
be extended : And with a view to preferve 
the arm fteadily in this fituation, a long 
fplint mould be laid along the fore-part 
of it, from the middle of the humerus to 
the tops of the fingers ; and this being 
properly fecure4 with a roller, the arm 
fhould be allowed to hang by the pa- 
tient's fide, to which it fhould be fixed by 
one or two ftraps. 

It is proper, however, to remark, that 
the arm fhould not be kept long in thift 
fituation, other wife a (tiffnefs of the 

elbow- 



Sect. X, Bonis of the fore- Arm, 91 

elbow-joint will very probably happen* 
With a view to prevent this, the bandage 
and fplint mould be removed about the 
eighth or tenth day ; when the fore^arm 
being for fome time moved flowly back- 
ward and. forward, and the joint rub- 
bed with any emollient oil* the arm may 
be again fecured as before. A cautious 
and daily repetition of this practice, while 
it prevents the occurrence of a ftiff joint, 
does not retard the cure. 



SECTION X. 

Of Fraclures of the Bones of the Wrift^ Hands f 
and Fingers i 



THE bortes of the ^rift being fmall, 
round, and fomewhat moveable, rea- 
dily yield to any ordinary force that may 
fee applied to them. On this account, they 
G 2 are 



9'i Of FraBures of the Ch. XXX1& 

are feldom fractured except by fhot from 
fire-arms, or a heavy weight pafling over 
them. 

The bones here are fo fmall that they 
do not readily reunite. For this reafon, 
as well as from the contiguity of tendons 
and ligaments, which gives rife to* high 
degrees of inflammation, a complete an- 
chylofis, or great ftiffnefs . of the joint, 
are common confequences of fracture of 
the bones of the wrifl. After replacing 
the bones, nothing proves fuch an effec- 
tual preventative of thefe effects as copious 
blood-letting from the injured parts by 
means of leeches, «in proportion to the 
violence ftf the fymptoms and the ftrength 
of the*patient : and this being done, the 
•anii and hand fhould be fupported by a 
fplint put beneath them, with another a- 
bove, in the manner we advifed in the 
lafl fection : and both fhould be fecured 
by a fimilar bandage and fling. 

In fractures of the metacarpal bones, 
after replacing them with as much ex- 
actnefs as poflible, a firm fplint, either of 

timber 



Sect. X. Bones of the Wrift, Hands, &c'. -93 

timber or ftrong pafteboard, mould be 
applied over the whole palms of the 
hand and infide of the arm, from the 
■ends of the fingers to the joint of the el- 
bow, in order to keep the hand as much 
extended as poflible, as the flexor mufcles 
of the fingers cannot be bent in any de- 
gree without altering the pofition of thefe 
bones ; and in order to guard againft this 
with as much certainty as pofiible, the 
long fplints mentioned above, with a fi- 
milar bandage, may be applied over the 
whole. 

Fractures of the fingers are frequent ; 
but when properly treated, the bones rea- 
dily unite, and the fingers become equal- 
ly ufeful as before. 

The bell fplint for a fractured finger 
is a piece of firm pafteboard exactly fit- 
ted to it, and foftened in water till it is 
eafily moulded into the form of the part. 
The finger being ftretched out and the 
bone replaced, this fplint fhould be ap- 
plied along the whole length of it, and 
Secured with a narrow roller : And in or- 
G 1 der 



94 OfFraBures of the Ch. XXXIX. 

der to prevent the injured parts from be- 
ing difturbed, a large fplint, either of the 
I fame kind of pafleboard, or of a thin 
piece bf wood glued upon leather, as is 
reprefented in Plate LXX. fig. 3, 4, 5. 
or 6. fhould be applied over the infide of 
the hand ; and the fingers being flretch- 
ed upon it, another roller mould be put 
over the whole, to fecure the fingers and 
hand, fo as to prevent them from having 
any kind of motion. 

With a view to preferve the motion of 
the joints of the fingers, the bandage 
and fplints fhould be removed about the 
tenth or twelfth day ; when the feveral 
joints of the finger being cautioufly bend- 
ed and extended different times, the 
whole fhould be tied up as before : And 
this being repeated daily, the fplints may 
with fafety be removed at the end of the 
third week ; when, by this piece of at-, 
tendon, the motion of the finger will be 
found complete, unlefs more than one 
bone has been broke, and at the fame 

time 



Se<5l. XI. Femur or 'Thigh-Bone. 95 

time fo much fplintered as to render this 
precaution impracticable. 



SECTION XL 



OfFraclures of the Femur or Thigh-Bone. 



EVERY part of the femur is expofed 
to fractures ; but it is more frequent- 
ly broke near to the middle than in any 
other part of it ; and next to this, that 
part of it termed the Neck of tl\e Femur 
is mod apt to fuffer. 

Fractures of all the under part of the 
femur are for the moft part eafily di- 
ftinguifhed, by the ufual grating noife of 
the ends of the bone on their being for- 
cibly rubbed together ; by the limb be- 
ing much fhortened if the fracture be 
oblique, or if the ends of the bone have 
been displaced in cafes of tranfverfe frac- 
G 4 tures ; 



96 OfFraBures of the Cli. XXXIX. 

tures ; by much pain and tenfion over 
the injured part ; and by the limb being 
rendered unable to fuftain the body. 

It is often difficult, however, to diflin- 
guifh fractures of the neck of the femur 
from diflocations of this bone. A due 
attention to the following circumftances 
will enable us in mod inftances to avoid 
miflakes of this kind, which are always 
attended with ferious confequences. 

In a great proportion of cafes, perhaps 
in nineteen of twenty, the head of the 
femur when diflocated is pufhed inwards 
j^nd downwards, owing to the brim of 
the acetabulum being not fo deep in this 
part as in others ? as well as to the mufcles 
at this particular part being not fo ftrong ; 
while perhaps in an equal number of 
fractures in the neck of the femur, the 
bone is pufhed upwards, owing to acci- 
dents of this kind happening moft fre- 
quently from falls upon the knees, or 
perhaps upon the feet when the legs are 
flretched out, by which a very confiderable 
force is necefTarily brought to act againft 

the 



IYatk. lxxt. 



L'lU.t. 



ElG. 








itTG, 4,. 




Seel. XT. Femur or Thigh -Bone. 97 

the neck of the thigh-bone, where it is 
leaf! able to give refiftance. In all fuch 
fractures, the leg is much fhortened, of- 
ten to the extent of feveral inches. The 
trochanter is accordingly found to be 
much higher than the trochanter of the 
other thigh ; and the knee and points of 
the toes are turned inwards. On the 
other hand, in thofe diflocations of the 
thigh-joint which we have mentioned, 
the leg is • confiderably lengthened, the 
head of the bone and the trochanter are 
difcovered near to the groin, with a cor- 
refponding vacancy where the trochanter 
ought to be, and the toes are turned 
out. 

In every fracture, a grating noife is 
difcovered on the ends of the bone being 
rubbed againfl each other ; and in all 
fractures of the neck of the femur, it is 
obferved that the leg and thigh may be 
turned with much more eafe from one 
fide to another, that is, the knee and 
foot may be moved with more eafe out-* 
wards or inwards, than when the head of 

the 



98 O/Fraaumofihe Ch. XXXIX. 

the bone is diflocated. We may likewife 
remark, that in diflocations the tumor 
Formed by the head of the bone and tro- 
chanter together, muft be always greater 
than in fractures, where the tumor is 
formed by the trochanter alone. 

In no part of furgery are we more apt to 
be difappointed than in the treatment of 
fractures of the thigh, particularly where 
the neck of the bone is broke. This 
proceeds from various caufes ; all of which 
mould be kept in view in forming a 
prognofis of the probable event of fuch 
cafes. 

1. The thigh-bone is fb thickly cover- 
ed with mufcles and other foft parts, that 
it is often with difficulty we can difco- 
ver the direction in which a fracture 
runs. 

2. We muft often, therefore, be un- 
certain whether the bones be rightly re- 
placed or not ; for where the courfe of a 
fracture cannot be afcertained with exact- 
nefs, we can never be fure of this being 
precifely effected. 

3. But 



Sect. XI. Femur or 'Thigh-Bone, 99 

3. But even where we are able to ao 
complifh the reduction of the fracture 
wn*h the utmoft nicety, we know from 
daily experience that it is extremely diffi- 
cult to retain the bones in their fitua- 
tion with fuch exactnefs as to prevent 
deformity. For when a fracture is ei- 
ther feated in the neck of the bone, or 
runs obliquely in any other part of it, it 
is fo difficult to prevent the bones from 
being difplaced merely by the ordinary 
action of the mufcles, that the limb is for 
the moft part rendered confiderably fhort- 
er than the other ; for in all fuch cafes, 
if the different parts of the bone cannot 
be fo placed and retained as to fupport 
each other, the under part of it will very 
certainly be drawn upwards. 

In fractures of the thigh too, other caufes 
concur to render it difficult to retain the 
bones in their fituation. They are more 
affected than fractures of other bones by 
every unufual exertion of the body ; par- 
ticularly by fneezing, coughing, and 
Jaughing ; nor can the pofture of the bo- 

dy 



I go QfFrafiures of the Ch. XXXIX. 

dy be in any way altered without affect- 
ing the thigh. 

In the reduction of a fracture of this 
bone, much difficulty was formerly ex- 
perienced from the pofition in which the 
limb was put during the operation. The 
body being placed either upon the floor, 
on a table, or in a bed, the limb was then 
extended, by which all the mufcles con- 
nected with it were put upon the flretch ; 
and as the extennon was continued till 
the bones were replaced, when this was 
accomplished with difficulty, the mufcles 
were often either violently tore afunder, 
or fo much weakened as not to be after- 
wards fit for ufe'; for fome of the muf- 
cles of the thigh being among the ftrong- 
cft in the body, a very coniiderable force 
was required to overcome the reuftance 
they afforded. But if the mufcles of the 
limb are relaxed, by making the thigh 
form an obtufe angle with the body, 
while the joint of the knee is moderate- 
ly bent, it is furprifing with- what eafe 
vse may, in moil cafes, place the bones 

in 



LATE. I.XXil. 

I'ICt.3. 




TIG. <£ 



jjg.t 



TTG.2. 




TJG.uT. 




Sect. XI. Femur or Tbigh-Bone, loi 

in their natural fituation. The caufe of 
refiflance is thus almoft entirely remo- 
ved ; fo that if there be not much ten- 
fion or fwelling, the ends of the bone 
may in general be eafily brought into 
contact, by one affiftant fecuring the up- 
per end of it, while the lower part of it 
is fupported and gently drawn down by 
another, the furgeon in the mean time 
being employed in putting the fractured 
parts together with as much exactnefs as 
poffible. 

The^ is moft difficulty in reducing 
fractures of the neck of the bone ; for 
the mufcles, in that fituation, being ex- 
ceedingly ftrong, and running in various 
directions, they cannot be relaxed fo 
completely as thofe of other parts of the 
limb. But even here we may, for the 
moft part, fucceed in the manner we have 
mentioned, the body being fecured h-f 
one affiftant, while moderate exteafion 
is made by another at the lower part of 
the thigh. It is proper, however, that 
practitioners be provided with inftru- 

ments 



102 * Of Fratturei of the Ch.XXXIX, 

ments for more powerful extenfion when 
the method now recommended fails. 
Different inftruments are delineated for 
this purpofe in Plates LXXVI. LXXVII. 
and LXXVIII. ; but thefe Ihould never 
be employed tiH every attempt in the 
ufual manner proves abortive. 

It is not, however, in replacing the 
bones, but in retaining them when repla- 
ced, that we encounter the greateft dif- 
ficulty. In tranfverfe fractures of this 
bone the practice is very eafy. After 
the fractured ends of it are brought into 
contact, they would for the mod part 
fupport each other with fufficient firm- 
nefs even without any bandage, if the 
patient could be confined to a proper 
pofture : But to prevent any riik from 
fudden exertions, the limb ihould be as 
firmly fee u red with fplints and a proper 
bandage, as is confiflent with a free cir- 
culation through the injured parts. 

For this purpofe two fplints are repre- 
fented in Plate LXX. fig. 4. and 6. One 
to reach from the top of the hip-joint 

to 



Setfb. XI. Femur or thigh-Bone. 1 03 

• 
to a little below the knee, of a breadth 
fufficient to cover at leaft one half of 
the thigh ; the other to reach from the 
groin to a little below the knee, and in 
breadth covering about a third part of 
the thigh. Of thefe, cohered with foft 
flannel, the longeft laid upon a twelve- 
tailed flannel bandage, is to be placed 
upon a thin pillow nearly as long as the 
thigh. The patient being placed in a bed 
made as tight as poflible with a firm hair 
mattrefs, fo that it may not fink or yield, 
his knee being moderately bent, and the 
bones accurately fet, the furgeon muft 
order the pillow, with the bandage and 
fplint above it, to be placed fo as the 
fplint may reach from the hip-joint 
along the outfide of the thigh to the 
knee. That this pofture of the leg and ' 
thigh may be eafily prefer ved, the pa- 
tient fhould not be laid directly upon his 
back, but turned fomewhat towards the 
affected fide ; and the knee and leg fhould 
be raifed rather higher than the body. 

The 



to4 Of Frdclures of the Ch.XXXIX, 

• 
The limb being thus placed in the po- 

(lure in which it is to be kept, the ihort 

fplint mentioned above muft be laid 

along the infide of the thigh from the 

groin to the knee, when the bandage pre- 

vioufly placed beneath the other fplint 

muft be applied, of fuch a tightnefs as to 

make an equal moderate preiTure over 

the whole thigh. 

As the cure would be much interrupt- 
ed, and might at lafl be very incomplete, 
were any part of the drefhngs to give 
way, it is a proper precaution perhaps 
in every cafe, to infert a long fplint of 
firm timber beneath the middle of the 
pillow, and to fecure it m its fituation 
by two broad flraps firmly buckled on 
the upper part of the limb. 

To obviate the motion of the limb, in 
confecjuence of involuntary ftartings, me 
pillow fhould be fixed to the bed by 
ftraps ; and to prevent injury or uneali- 
nefs from the weight of the bed-clothes, 
two or three hoops fixed in a proper 
frame mould be placed over the thigh. 

When 



Scd. XI. Femur or Thigh-Bone. 1 05 

When no untoward fymptom occurs, 
the limb might be left in this fituation 
till the cure was completed ; but left 
the bones mould by accident be difpla- 
ced, and efpecially if the limb mould 
fwell and become painful, the bandage 
mould be undone, and the upper fplint re- 
moved, in order to admit of the parts be- 
ing examined with accuracy. The twelve 
or eighteen-tailed bandage admits of this 
being done without the limb being di- 
fturbed. In the event of pain, fwelling, 
or inflammation, it may be proper, be- 
fore renewing the dreflings, to apply 
leeches and other remedies to the parts 
affected ; but when none of thefe take 
place, and when the bones are found in 
their fituation, the fplint mould be im- 
mediately replaced and fecured with the 
bandage as before. 

In healthy adults, when the cure pro- 
ceeds without interruption, it will in ge- 
neral be completed in the courfe of fix 
weeks ; but violent exertion of every 

Vol. VI. H kind 



io6 Of FraZurcs of the Ch.XXXIX. 

kind fhould be avoided till the eighth or 
tenth week has pafTed over. 

We have advifed the limb to be placed 
in fuch a pofture as tends molt effectual- 
ly to relax all the mufcles connected with 
it. But although this may be highly 
proper at firft ; yet there is no neceflity 
for perfevering in it during the whole 
courfe of the cure. On the contrary, it 
proves often very prejudicial, as the limb,, 
if it be kept invariably in one pofture 
for fix or eight weeks, as is too frequent- 
ly practifed, is very apt to become ftifF 
and unwieldy, fo as to be afterwards pro- 
ductive of much uneannefs and diftrefs. 
At the end of a fortnight, or even in lefs 
time than this, the patient may be allow- 
ed to turn more towards his back, and 
the joint of the knee may be fomewhat 
ftretched out. If this be done with cau- 
tion, it may be repeated daily ; that is, 
the leg may be alternately ftretched out 
and bent ; by which the motion of the 
whole limb will be much more free and 

entire 



Sect. XI. Femur or 'Thigh-Bone. 107 

entire at the end of the cure than we 
ufually find it to be. 

In a great proportion of cafes where 
cures are practicable, the mode of treat- 
ment we have here pointed out will 
prove fuccefsful. It will never fail in 
tranfverfc fractures, if all the parts of it 
meet with proper attention : but altho' 
it will often fucceed where the bone is 
broke very obliquely ; yet it mufl be 
confefTed, that cafes of this kind fome- 
times occur in which it fails entirely, 
the ends of the bone flipping paft each 
other, and the limb becoming much fhort- 
er than it ought to be, notwithstanding 
all our efforts to prevent it. 

Indeed, an effectual method of fecu- 
ring very oblique fractures in any of 
the bones of the extremities, and efpeci- 
ally of the thigh-bone, is perhaps one of 
the greateft defiderata in modern fur- 
gery. In all ages, the difficulty attend- 
ing this' has confefTedly been very great ; 
and frequent lainenefs from Ihortened 
limbs proceeding from this caufe, evi-' 
H 2 dently 



log O/FraBures of the Ch.XXXlX, 

dently mows that we are ftill deficient 
in this branch of practice. 

The treatment of fractures being one 
of the molt important branches of fur- 
gery ; to prevent lamenefs, one of our 
firft objects, much ingenuity has been 
Ihown in the invention of fome method 
by which this purpofe might be anfwer- 
ed. It has been propofed, and by feve- 
ral practitioners has been attempted, in 
fractures of the thigh, to fecure the pa- 
tient's body, as one fixed point, by means 
of different bandages, to the upper part 
of the bed, and by an axis in peritrochio 
at the foot of the bed, to make fuch a 
degree of extenfion as might be fully 
equal to the purpofe- of retaining the- 
fractured bones. But all who are ac- 
quainted with the fretful irritable flate 
in which patients with fractures com- 
monly are, and with the pain which tight 
bandages always excite, will know, that 
although propofals of this kind t nay ap- 
pear to advantage in theoretical difqui- 
fitions, they will never probably be of 

real 



IIA-TT,. T.XXTU . 




Ere. 2. 





Sect. XL "Femur or Thigh-Bone, 109 

real utility. And accordingly none of 
them have ever been admitted into gene- 
ral practice. 

The invention of the late Mr Gooch 
of Norwich, is the one which promifes 
to be of the greateft utility in oblique 
fractures of the thigh. This inftrument 
is delineated in Plate LXXII. and in an 
improved date by Dr Aitken in Plate 
LXXIII. 

A broad firm ftrap of leather, lined 
with quilted cotton or foft flannel, is 
placed on the upper part of the limb, and 
fecured by buckles of fuch a tightnefs as 
the patient can eafily fupport. A firm- 
lar flrap is put round the under part of 
the thigh, and made to reft chiefly on the 
condyles of the femur. Two or three 
fteel fplints, connected with the ftraps, 
pafs from one to the other in fuch a 
manner, that by means of them the 
ftraps can be forced afunder, and retain- 
ed with the greateft certainty at any di- 
fiance during the cure. 

For a more particular account of this 
H 3 apparatus. 



no OfFraBurts Ch. XXXIX. 

apparatus, the explanation of the plates 
may be confulted. 

In forae cafes, however, the pain, fuel- 
ling, and inflammation, are fo confider- 
able, as to preclude the application of 
the moll fimple bandage. After endea- 
vouring to relieve the fymptoms by lo- 
cal blood-letting and other remedies, Mr 
Gooch's method, or Dr Aitken's, may 
be adopted, if practicable ; if not, the 
cure muft be conducted in the ufual way, 
with the hazard of the ends of the bone 
pamng one another, and of the limb be- 
ing ihortened. But in this event, under 
the circumftances we have juft mention- 
ed, although the patient may regret his 
misfortune, he cannot with propriety or 
juftice blame the furgeon. 



SECTION 



Sea. XII. of the Patella. . lit 



SECTION XII. 



Of FraBures of the Patella. 



THE patella or knee-pan is liable to 
fractures from falls and bruifes up- 
on the knee. Tranfverfe fractures are 
moft frequent ; but we meet with in- 
ftances of longitudinal fractures in this 
bone, and in fome cafes it is broke into 
three or four different pieces. 

In fractures of the patella, we are in 
general defired to make a very guarded 
prognofis ; as by moft writers upon this 
fubject, it is faid that they almoft con- 
ftantly terminate in a fliff joint, owing, 
as is fuppofed, to the callus forming in too 
great quantity, and to its finding accefs 
to the cavity of the joint. I have not 
found, however, that fractures of this 
bone are fo apt to produce fliff joints as 
H 4 we 



1 12 Of FraBures Ch. XXXIX. 

we are led to expect. In different inftan- 
ces which I have had of them, fcarcely 
any degree of ftiffnefs remained in any 
of them after three or four months : and 
when any permanent affection of this 
kind does take place, I cannot imagine 
that it proceeds from fuperabundancy of 
callus, as the quantity which fuch a fmall 
bone will afford, mufh be extremely tri- 
fling. It rather feems to originate from 
the inflammation with which thefe frac- 
tures are ufually accompanied affecting 
the internal parts of the joint ; or from 
the knee being kept too long in an ex- 
tended immoveable pofture. From a 
dread of feparating the fractured parts 
of the bone before they are firmly uni- 
ted, the leg is ufually preferved in an 
extended pofture for fix, eight, or per- 
haps ten weeks;" a much longer period 
than is neceffary, and by which alone 
even the foundeft joint would be apt to 
become ftiff and immoveable. 

In the treatment of fractures of this 
bone, in whatever direction they may 

run, 



Sed. XII. of the Patella. 1\t ) 

run, the leg mould be extended, in order 
to relax the only mufcles with which it 
is connected, thofe forming the ligament 
inferted into it. With this view, the pa- 
tient mould be placed upon a bed ren- 
dered fo firm that it will not yield du- 
ring the courfe of his confinement ; a 
precaution particularly neceffary in all 
fractures of the lower extremities, where 
long confinement to bed is almofl always 
neceffary, and where unequal finking of 
the body is often the fource of much 
uneafinefs to the patient, and may be the 
caufe of a feparation of the newly' repla- 
ced bones. 

This being done, a long firm fplint of 
timber, thickly covered with foft wool, or 
with feveral plies of fine flannel, fhould 
then be placed beneath the thigh and leg, 
from the upper part of the one to the ex- 
tremity of the other ; and to this the limb 
fhould be fecured by two ftraps between 
the ankle and knee, and one or two be- 
tween the knee and top of the thigh. This 
will effectually preferve the leg in a ftate 

of 



114 Of Fraaures Ch. XXXIX. 

of extenfion ; and it does it in the eafieft 
manner when the fplint is fufficiently 
broad and properly covered in the way 
we have mentioned. 

The different parts of the fractured 
bone are now to be brought as nearly to- 
gether as pomble with the hand ; but no 
bandage is yet to be applied to them. 
Our great object at firft is to prevent in- 
flammation ; for which purpofe as much 
blood mould be taken from the joint by 
means of leeches as the patient can pro- 
perly bear ; and for two or three days, or 
fo long as much pain, fwelling, or ten- 
fion continue, faturnine and other aftrin- 
gent applications mould be ufed for re- 
moving them. 

This being accomplifhed, we again ex- 
amine the ftate of the bone ; and if the 
different parts of it be all as nearly in 
contact as is neceflary, they ought not to 
be difturbed. The joint may be cover- 
ed with a large pledgit of Goulard's ce- 
rate, by which it will be kept foft and 

eafyj 



Sed. XII. of the Patella. 1 15 

eafy ; and a hooped frame mould be em- 
ployed to Tupport the bed-clothes. 

But if the different parts of the bone, 
inftead of being nearly in contact, are 
found feparated to any considerable dif- 
tance, it becomes neceffary, in the firffc 
place, to replace them, and afterwards to 
retain them with bandages as far as this 
can with propriety be done. 

In a longitudinal fracture of the pa- 
tella, this is eafily accomplifhed j for in 
this direction we meet with little refift- 
ance in replacing them, and they are ea- 
fily retained with very moderate pref- 
fure, either with the common uniting 
bandage, or with flips of leather fpread 
with glue or adhefive plafter. But in 
tranfverfe fractures of this bone, as that 
portion of it connected with the extenfor 
mufcles of the thigh is apt to be drawn 
forcibly upwards, we cannot always re- 
place it ; or if this is prafticable, it can- 
not always be retained in contact with 
the inferior portion, but by a force that 

would 



Ii6 OfTraBures Ch. XXXIX. 

would excite pain, fwelling, and inflam- 
mation. * 

It is a fortunate circumftance, how- 
ever, that it is not abfolutely neceflary 
to a complete cure, that the different 
pieces of bone be kept in exact contact. 
Where it can be eafily done, it ought al- 
ways to be put in practice ; but I know 
from the refult of feveral cafes where 
this was impracticable, that a cure may 
be obtained, and the joint be equally firm 
and ufeful as it was before, even although 
the feparated portions of bone cannot be 
brought within an inch' of each other. 
We fhould not therefore be very anxious 
about this ; and inftead of ufing much 
force for the purpofe of drawing the 
bones into clofe contact, no more mould 
be employed than the patient can bear 
with perfect eafe. 

Various bandages have been invented 
for drawing the divided parts of a frac? 
tured knee-pan together ; but all of them 
have been formed upon erroneous prin- 
ciples. They are made to prefs equally 

upon 



Sea. XII. of the Patella. 1 1 7 

upon the upper and under portion of the 
bone : whereas the leaft reflection on the 
anatomical ftruclure of the parts muft 
render it obvious, that no advantage can 
be derived from much preflure on the 
inferior part of the bone, which always 
remains in its natural fituation ; and 
therefore, that any force we employ 
fhould be almofl entirely applied to that 
part of it connected with the ligament 
of the extenfor mufcles ; by the action 
of which, particularly of the rectus 
mufcle, this portion of the bone is drawn 
upwards. 

In plate LXXV. a bandage is repre- 
fented ; from which, while it fits eaiily 
upon the parts to which it is applied, 
every advantage which can be expected 
from this kind of afliftance may be de- 
rived. It confifts of two circular (traps, 
A B, of firm leather, lined with foft flan- 
nel, with two perpendicular ftraps C E, 
that pafs from one to the other, and a 
femilunar firm comprefs G ; with another 
ftrap of a greater length D, reaching 

from 



sit OfFraaures Ch. XXXIX, 

from the point of the toes to the buckle on 
the upper circular ftrap round the thigh, 
as is more particularly reprefented in 
fig. 3. of the fame Plate. 

The leg being extended and elevated 
to a proper height for relaxing the ex- 
tenfor mufcles of the thigh, the upper 
edge of the under circular ftrap A fhould 
be applied to the under part of the infe- 
rior portion of the bone, fo as to fupport 
it in its aiatural fituation without forcing 
it farther up. The ftrap muft be then 
buckled to fuch a degree of tightnefs as 
the patient can eafily bear it ; and the 
upper half of the bone being pulled gent- 
ly downwards, the femilunar comprefs F 
in fig. 3. muft be applied round the upper 
end of it, when the upper circular ftrap 
muft be alfo buckled. By means of the two 
perpendicular ftraps and buckles, we now 
make an eafy gradual extenfion, which 
will not move the under circular ftrap 
if it be made fumciently tight ; but which 
will draw the other downwards if it be 
not made too tight, which we ought care- 
fully to endeavour to avoid. This will, 

in 



Sect. XII. of the Patella. 119 

in fome degree, draw down the upper 
part of the bone, by gently pulling down 
the comprefs previoufly applied to the 
upper end of it ; but it will be more 
effectually done by the ftrap D made 
fufficiently tight by fixing it to the cor- 
refponding buckle in the upper circular 
ftrap B. 

In this manner the different parts of the 
bone may be made to approach each other 
as far as this can be done with propriety ; 
but for the reafons already mentioned, 
the preffure mould never be carried fo far 
as to endanger the excitement of pain, in- 
flammation, or fwelling. 

The limb being fecured in the manner 
we have mentioned, the bandages mould 
not be removed till the twelfth or four- 
teenth day, if pain and inflammation do 
not render a more early removal necef- 
fary. But about this period the joint 
fliould be expofed, when the limb may be 
moderately bent ; and this being cau- 
tioufly repeated every fecond or third 
day, no interruption will be given to the 
cure, while the motion of the joint will 

be 



i 20 OfFraBures Ch. XXXlX; 

effectually preferved ; which it feldom or 
never is when this piece of attention is" 
neglected. 

There is another injury to which the 
joint of the knee is liable ; fo fimilar in 
its effects to the one we have been conli- 
dering, and in the mode of treatment, 
that I think it right to mention it here ; 
namely, a feparation, by external vio- 
lence, of the ligament or tendon of the 
rectus mufcle from the patella. The 
ufual effect of a finart ftroke, or a fevere 
fall, upon the fore- part of the knee, is a 
fracture of the patella : but where a per- 
fon carrying a heavy burden upon his 
back, falls with his knee much bent, a 
rupture of the tendon is a more frequent 
confequence ; at leafl I have met with 
three cafes of this accident from this 
caufe, in which the tendon, after fepa-* 
rating from the bone, retracted to the 
diftance of two or three inches. 

The treatment we have advifed for a 
fracture of the patella proves equally 
fuccefsful here ; Only it will be under- 

flood 



Se6l. XII. of the Patella, tit 

Hood, that in this cafe no advantage can 
be obtained from pulling down the re- 
tracted tendon : for no part of the bone 
being connected with it, we cannot lay 
hold of it ; fo that we have to truft fole- 
ly to the extended pofture of the limb* 
But although the tendon and bone can- 
not be brought clofe to each other, yet 
a cure may always be accomplifhed in 
the manner we have mentioned. 



SECTION XIII. 



Of FracJures of the Bones of the Leg, 



IN fractures of the leg, one bone on* 
ly is often broke ; but a fracture of 
both is more frequent. In this cafe the 
feat, as well as the direction of the frac- 
ture, are readily difcovered. When one 
bone only is broke, thefe are difcovered 
Vol. VI* I wi& 



122 Of Fractures of the Ch.XXXIX. 

with more difficulty. This, however, is 
of no great importance ; for when one 
of the bones remains entire, it ferves fo 
effectually to fupport the other, that no- 
thing is neceffary for effecting a cure 
but confinement till the fractured bone 
be united. 

Fractures are more frequent near the 
joint of the ankle than in other parts. 
We find a great proportion of fractures of 
the fibula feated an inch or two above 
the under extremity of this bone, this be- 
ing the weakefl part of it. 

In the management of a fractured leg, 
the fame general principles apply which 
we advifed in the treatment of a fractu- 
red thigh-bone. In replacing the bones, 
the mufcles of the limb mould be as 
much relaxed as poffible ; and we do it 
in the mofl effectual manner by bending 
the joint of the knee, and flightly ex- 
tending <the foot. When the leg is in 
this pofitivin, there is feldom much diffi- 
culty in putting the bones into their na- 
tural fituations ; and with no more ex- 

tenfion 




Era 2. 




Sea. Ml. Bones of the Leg. 123 

tenlion than can with great eafe be gi- 
ven, by one afliftant at the upper end of 
the limb, and another fupporting it at the 
ankle. 

This being done, and the patient placed 
in fuch a manner that the injured leg may 
with eafe be laid upon its outride, with the 
knee bent, the fplints, ng. 3, 5, or 6, Plate 
LXX. mould be applied and retained with 
the twelve-tailed bandage ; the fplint on 
the outfide of the leg reaching from a little 
above the knee to beneath the ankle, with 
a view to prevent the motion of either of 
thefe joints, by which the bones are apt 
to be difplaced. 

Whether the fplirtts are of firm pafte- 
board, or fuch as are reprefented in Plate 
LXX. they would, for the mofl part, 
prove fufficient : but when the patient is 
either very reftlefs, or troubled with fpaf- 
modic affeclions of the mufcles of his 
leg, an additional fplint of wood, fhaped 
to the form of the leg, as is reprefented 
in fig. 1. and 2. of the fame plate, mould 
be applied along the outride of it ; and, 
I 2 if 



124 OfFraSfuresofthe Ch.XXXIX. 

if it be llightly excavated and filled with 
foft wool, it fits with perfect eafe, while 
it prevents, with the utmoft certainty, 
the ends of any of the bones from fall- 
ing downwards. It is fixed with any 
degree of tightnefs by two ftraps and 
buckles. The leg, when drefled in this 
manner, has the appearance reprefented 
in Plate LXXIV. fig. a. 

We have already obferved, that after 
the dreflings are applied, the leg mould 
be laid upon its outride, with the knee 
bent, and the foot mould be fome- 
what fupported by a turn of a bandage, 
as reprefented in the figure juft mention- 
ed. The intention of this is to relax 
the mufcles of the limb ; by which the 
patient lies with more eafe, while the 
bones are lefs liable to be difplaced, than 
where the mufcles are kept fully ftretch- 
ed out, as was almofl the univerfal cu- 
ftom till very lately. 

But although it is proper to place the 
leg in fuch a pofture as tends mod effec- 
tually to relax all the mufcles j yet the 

knee 



Sea. XIII. Bones of the Leg. 125 

knee fhould not be more bent than is 
neceflary for this purpofe : for when the 
joint is much curved, it is almoft equal- 
ly irkfome to the patient as when the leg 
is fully ftretched out. The knee mould 
not therefore be more bent, nor fliould 
the patient be laid more towards the af- 
fected fide, than is juft neceflary for al- 
lowing the leg to be placed upon its 
outfide. 

There are fome patients, however, 
who, from long cuftom, as well as from 
other caufes, cannot reft when lying on 
either fide ; and fome practitioners think, 
that fractures of the leg mend better 
when the patient is laid upon his back, 
and the limb placed upon the gaflrocne- 
mii mufcles, with the toes upwards. In 
fuch cafes the patient may be placed up- 
on his back, and yet the curved pofition 
of the leg retained. This may be done 
in different ways ; but the eafieft me- 
thod is, by raifing the leg, and fupport- 
ing it upon a frame, at a proper height 
above the level of the body. This ad- 
I 3 mits 



126 Of FraBures of the Ch.XXXIX. 

mits of the limb being placed in the po- 
flure we have mentioned, and with any 
neceflary degree of curvature. 

Even where a fractured leg is placed 
pn the outfide, it is a pleafant variety to 
the patient to have the poflure altered : 
and by means of fuch a frame it can be 
eahly done. 

A limb placed in this ntuation is re- 
prefented in Plate LXXX. fig. 2. This 
variety of poflure is even admiflible in 
fractures of the thigh. The patient may 
from the firfl be placed with his leg 
curved in the manner here reprefented ; 
or he may afterwards turn upon his back, 
and the cure be completed while he re- 
mains in this poflure, or he may alter- 
nately change from one to the other. 
The inconveniency ufually complained 
of, from the leg refling upon the heel 
when it is flretched out, is avoided by 
an excavation or opening made in the 
bottom of the frame for receiving the 
heel ; or it may be done by allowing the 
heel to projed; over the edge of the frame 

altogether. 



Seel. XIII. Bones of the Leg. 127 

altogether. No change of pofture, how- 
ever, ought to be permitted for the firft 
ten or twelve days. About this time 
the patient may be turned with caution 
upon his back, and the leg moved from 
one pofition to the other, care being 
taken to preferve. it in the fame degree 
of curvature. 

In fractures of the leg where the fibu- 
la only is injured, it is apt to pafs unno- 
ticed, and to be confidered as a fprain of 
fome of the mufcles : But as very ferious 
confequences are apt to enfue from this 
miftake, it ought to be ftrictly guarded 
againft. 

When treating of fractures of the cla- 
vicle, we had occafion to mention an ap- 
pearance which, of itfelf, is extremely 
fimple and of eafy treatment ; but which, 
from want of attention to the caufe of 
it, has often been productive of much 
perplexity both to patients and practi- 
tioners ; L mean what is commonly term- 
ed the Riling End of a Bone : and as this 
I 4 frequently 



12$ O/FraBures of the Ch. XXXIX. 

frequently occurs in the leg, I think it 
proper to mention it here. 

When the bones of the leg are broke di-* 
rectly acrofs, they fometimes ferve to fup.» 
port each other fo effectually that neither 
of them are difplaced. In fuch circum- 
fiances no inequality appears in the limb, 
if it be not from fome temporary fwel- 
ling of the foft parts. But when both 
bones are fractured, and at the fame time 
difplaced, the under extremity, or that 
portion connected with the foot, is al- 
moft always drawn towards the back 
part of the leg ; by which an unequal 
prominency is produced by the project-, 
ing end of the upper portion of bone, or 
that part of it which ftill remains con- 
nected with the knee. 

It is this which in general is termed 
the Rifing End of the Bone : and in re- 
ducing fuch fractures much pains has of- 
ten been taken to force a bone in this fi- 
tuation into contact with the others. It 
is obvious, however, that it is not the 
upper part of the bone which rifcs, but 

the 



: '..v:k 



TIG-. 1 



T'IG. 2. 





FIG. ,r 




Sect. XIII. Bones of the Leg, 1 29 

the inferior portion which falls, or is 
drawn out of its natural fituation by the 
weight of the foot, as well as by the con- 
traction of the mufcles on the back part 
of the leg : Hence no advantage can be 
gained by any preflure made upon the 
fuperior part of the bone, while much 
harm may be done by it ; as has often 
happened by bandages being put fo tight 
upon it as to cut all the teguments with 
which it was covered ; and thus forming 
a compound fracture of what otherwife 
would have remained of the moll fimple 
kind. 

The upper part of the bone never rifes 
out of its natural fituation j fo that any 
inequality that occurs on the form and 
appearance of the leg, muft be produced 
in the manner we have mentioned, name- 
ly, by the inferior portion of the bones 
being drawn out of the fituation which 
they ought to occupy: fo that in our 
treatment of fuch affedions, inftead of 
forcing down the upper part of the bone, 
our fole objed fhould be to raife the in* 

ferior 



?3© OfFraBures of the Ch.XXXIX. 

ferior part of it, fo as to bring them in- 
to contact ; and by fupporting it in this 
iituation, to endeavour with as much cer- 
tainty as pornble to effect their reunion. 
In this manner a cure may be often ac- 
complished, which would not in any other 
way have been practicable. 



SECTION XIV. 



OfFraBures of the Bones of the Foot and Toes. 



THE foot is very liable to injuries of 
this kind from a variety of caufes ; 
but particularly from its being more ex- 
pofed to bruifes than other parts of the 
body. 

Fractures of thefe bones are diftin- 
guiihed in the fame manner with fractures 
of other parts. We judge that one or 
other.of them may probably be fractu- 
red. 



Sect. XIV. Bones of the Foot and Toes, 1 3 1 

red, when the foot has been violently 
bruifed ; and we difcover with certainty 
that it is Co by the grating of the fractu- 
red parts when they are rubbed againft 
each other. 

Fractures of the bones of the foot and 
toes are to be managed nearly in the 
fame manner with fimilar injuries of the 
hands and fingers. Any portion of bone 
that is difplaced mufl be put into its na- 
tural Situation with as much exactnefs as 
poflible ; and we endeavour to retain it 
by a fplint fitted to the form of the part, 
fupported with different turns of a roll- 
ler. When any of the bones of the foot 
are fractured, a large fplint fhould be ap- 
plied over the fole, fo as to fupport the 
whole of it ; and no freedom fhould be 
permitted in the motion either of the 
foot or ankle during the cure ; for no- 
thing tends more to difplace a fractured 
portion of bone than the action of con- 
tiguous mufcles. 



SECTION 



I $2 Of Compound Fraftum. Ch. XXXIX. 



SECTION XV. 



Of Compound Fraftures. 

AS the term Compound Fradlure has 
been applied to injuries of different 
kinds, I think it right to define with pre- 
cifion the meaning I wifh to affix to it. 
A fradlure of a bone communicating 
with an external opening or wound in 
the correfponding teguments, I denomi- 
nate a Compound Fradlure. It is not 
the circumftance of a fradlured bone oc- 
curring with a wound in the contiguous 
foft parts that conftitutes a compound 
fracture : This may happen with a frac- 
ture of the moil fimple nature. Unlefs 
the external opening communicates with 
the fradlure of the bone, the nature of 
the injury is not* affected by it, even al- 
though 



Sect. XV. Of Compound FraCturcs. 133 

though the wound be extenfive ; while 
the fmalleft puncture parting directly to 
the fubftance of a fractured bone, adds 
much difficulty to the method of cure, 
and hazard to the event. 

Compound fractures are produced by 
external violence, and frequently by the 
bones, in cafes of fimple fractures, being 
pufhed through the correfponding tegu- 
ments. In fome cafes, this happens from 
a bone being fractured fo very obliquely 
as to terminate in a fharp point ; while 
in others it is an evident effect of too 
tight a bandage, applied with the impro- 
per view, as we have feen in one of the 
preceding fections, of bearing down the 
upper end of the fractured bone. But in 
whatever way a compound fracture is pro- 
duced, the confequences refulting from it 
are nearly funilar. The admimon of air 
to a fracture adds evidently to the rifk at- 
tending it ; and whether this takes place 
as an immediate effect of external vio- 
lence, or as the confequence of preflure 
upon the ends of the bone, no difference 

as 



134 Of Compound Fraflurcs. Ch. XXXIX; 

is perceptible in the efFe<fls which refult 
from it. 

Various reafons might be adduced to 
prove that it is the admimon of air alone 
which renders compound fractures more 
hazardous than others. We may fhortly 
mention, however, one of the mofl ob- 
vious proofs of it. The worft variety of 
fimple fracture, where the bone is broke 
in the mofl oblique manner, and where 
it is difficult or perhaps impoflible to re- 
tain it in its fituation, will continue to 
do well, and to excite no fevere fymp- 
tom, as long as the fkin remains entire : 
But if, by any accident, the point of the 
bone is pufhed through the teguments, 
from that moment the pain becomes 
more fevere ; the inflammation, which 
before perhaps was trifling, becomes now 
confiderable ; fever takes place ; the 
limb is apt to be attacked with violent 
fpafmodic twitchings ; and to thefe there 
frequently fucceeds either gangrene or 
extenfive fuppurations. 

In compound fractures, our firft ob- 
ject 



Sed. XV. Of Compound Fr aft ures." 135 

ject is to reftrain profufe hemmorrhages 
when they take place, by a proper appli- 
cation of the tourniquet : Our next is to 
connder, whether we are to attempt to 
five the limb, or to recommend imme- 
diate amputation. 

From the difficult treatment and un- 
certain event of compound fractures, 
practitioners have been very univerfally 
difpofed to connder the amputation of 
the fractured limb as indifpenfably ne- 
cefTary. At all times indeed individuals 
have oppofed this general opinion. *A- 
mong others, Mr Bilguer of Berlin wrote 
on this fubject ; and he afferts, that am- 
putation is fcarcely ever requinte, and 
that a greater number of patients would 
recover by proper treatment than by the 
operation. 

To me it appears that both opinions 
are in the extreme ; and that they have 
been formed without that attention to, 
and difcrimination of, circumftanees, 
which the importance of the queftion 
required. 

In 



136 Of 'Compound Frafiures. Ch. XXXIX* 

In private practice, where patients can 
be kept quiet and perfectly at reft from 
the date of the injury, and where proper 
attention can be infured on the part of 
the practitioner, as well as of experien- 
ced nurfes, compound fractures fhould 
receive a different treatment from thofe 
that happen in a field of battle or in an 
engagement at fea. There are fo many 
inftances in which, from amputation be- 
ing objected to by the patient, from the 
limb being too much fwelled or inflamed 
before aihftance was called to allow of 
its being performed, or from intention 
on the part of the practitioner to endea- 
vour to fave the limb, of cures being 
made, that I am now convinced that im- 
mediate amputation fliould never be ad- 
vifed in private practice, unlefs when the 
bones are fo much fhattered that they 
cannot reunite ; or where, from the vio- 
lence of the injury, the texture of the 
loft parts is completely deftroyed. 

On 



Sea. XV. Of Compound Frafium. 1 37 

On the other hand, I am fatisfied that 
it would be a good general rule, both in 
the navy and army, to amputate imme- 
diately in every cafe of compound frac- 
ture received in battle, where the acci- 
dent is either in the humerus or thigh, 
or where both bones of the fore- arm or 
leg are broke. In this lituation, the pa- 
tient is expofed to a variety of hardships 
which tend to aggravate his danger ; 
and no accommodation can be procured 
nor attention given to leffen it. 

In opposition to this it may be' alleged, 
that many cures of compound fracture 
are daily made in military hofpitals. In- 
deed this is the argument on which Mr 
Bilguer refts his opinion : but like eve- 
ry prejudiced inquirer, he ftates it par- 
tially. 

1 readily admit, as every one accu- 
ftomed to the treatment of fractures will 
do, that cures are fometimes unexpected- 
ly accomplished under the moft unto- 
ward circumftances : But the favourable 
termination of a few cafes ought not to 

Vol. VI. K inva- 



138 Of Compound FraStures. Ch. XXXIX, 

invalidate a rule of fuch confequence as 
this, which is founded on the fure bans 
of experience and obfervation. 

When an officer of rank and fortune 
receives a compound fracture, and where 
circumftances- admit of his being foon 
conveyed to comfortable quarters, with 
a profpect of his remaining there during 
the cure, the cafe muft be a bad one if 
we do not attempt to fave the limb. But 
cafes of this kind are not in the ufual 
routine of military practice ; and I men- 
tion thern particularly, becaufe the ac- 
counts we have received of the fuccefs 
of the practice inculcated by Mr Bilguer, 
are chit fly, if not entirely, drawn from 
iiich inftances ; and they therefore afford 
no conclufion relative to military and 
naval practice in general. 

Even in private practice, I am far from 
thinking that our attempts to fave frac- 
tured limbs will always fucceed. I know 
they will not ; and, in the courfe of 
much bufinefs, that cafes will occur in 
which the belt conducted meafures will 

fail, 



Sect. XV. Of Compound TraBures. 139 

fail, particularly where the large joints 
are much injured, and where the long 
bones are not only fractured but broke 
into fplinters in different places : But I 
know from experience, that in a great 
proportion of the whole, We will prove 
fuccefsful ; and that in thofe cafes iri 
which we are at lafl obliged to advife 
amputation, more will recover than pro- 
bably would have done if the operation 
had been performed foon after the acci- 
dent : at lead this has been very commonly 
the cafe in the courfe of my obfervation. 
Of thofe who have died foon after the 
operation, either from the fever induced 
by the extenfive wound ; from the great 
and fudden change produced in the cir- 
culating fyftem by the removal of a con- 
fiderable part of the boply ; or from the 
perturbation and violent agitation of fpi- 
rits which the unexpected lofs of a limb 
mull always induce, a great proportion 
has been of thofe cafes where the operation 
was performed as qukkly as poffible after 
the accident. In thefe, the various caufes 
K a we 



140 Of Compound Fraff arcs. Gi. XXXIX* 

we have mentioned concur to render 
the fubfequent fever, and every conco- 
mitant fymptom, more violent than we 
commonly find them in patients who 
have been reduced by confinement and 
a low regimen, and who, from having 
full leifure to reflect upon the danger of 
their fituation, are, from their own con- 
viction of its being neceflary, very rea- 
dily induced to fubmit to the operation, 

A patient may indeed be brought fb 
low as to make the fuccefs of the opera- 
tion doubtful from this caufe alone : But 
a practitioner may always guard againft 
this, by proposing the operation when his 
attempts to fave the limb prove abortive, 
and when the patient's ftrength declines. 

Amputation proving more fuccefsful 
in the more advanced flages of com- 
pound fractures than when practifed im- 
mediately after the accident ; and in the 
more advanced ftages of chronic affec- 
tions, particularly in white fwellings of 
the joints, as we have elfewhere remark- 
ed, than in the more early periods off 

them; 



rr.ATi<: i.xwi 



I'IG. 1 




"Sect. XV. Of Compound FraBures. 141 

them ; is a point which merits the at- 
tention of practitioners. So far as my 
obfervation goes, I confider the fact as 
afcertained ; and if the experience of 
others leads to the fame conclusion, it 
will prove the molt convincing argu- 
ment againft early amputation. In the 
Courfe of my own experience, I do not 
recollect an inftance of death occurring 
from the operation alone, where the af- 
fection for which it was advifed was of 
fome duration ; and in feveral inflances 
it has been performed where the patient 
was very much exhaufled : Whereas fe- 
veral have died merely from the opera- 
tion, where it has been put in practice 
foon after the accident. When I fpeak 
of death as the confequence of the ope- 
ration, I do not mean fuch inflances of it 
as occur from hemorrhages breaking out 
in the courfe of a fhort time after the pa- 
tient is laid in bed, as thefe may happen at 
whatever period a limb may be amputated j 
but fuch as take place about the fecond or 
third day, and in fome inflances at a la- 
K 3 ter 



142 Of Compound TraBures. Ch.XXXlX, 

ter period, from the violence of the fe r 
ver induced by and commencing foon af- 
ter the operation. 

When amputation is not performed 
immediately, or foon after the injury is 
received, it is agreed upon all hands, 
that it cannot, for feveral days at leaft, 
be admimble. Different caufes may af- 
terwards render ;it neceffary. 

i. Hemorrhages under certain cir- 
cumftances. 

2. Extenfive mortification. 

3. The ends of the fractured bones re- 
maining long difunited, while a copious 
difcharge of matter endangers the fink- 
ing of the patient's ftrength. 

When hemorrhages take place imme- 
diately, we have it always in our power to 
command them, either by compreffion a- 
lone, or by enlarging the wound when it 
is too fmall, and fecuring the bleeding ar- 
teries with ligatures. Sometimes, how- 
ever, when no difcharge of importance 
occurs at firft, profufe hemorrhages will 
take place at the end of feveral days. It 

may 



Se&. XV. Of Compound FraEl tires. 143 

may be difficult in fome cafes to account 
for this ; but we can frequently trace it 
to the efFecl of friction ; the coats of an 
artery being destroyed by beating or 
rubbing upon the {harp edge of a fplin- 
tered bone. 

Even in this advanced ftate of the in- 
jury, we may frequently beable to fecure 
the wounded arteries with ligatures. But 
the limb is fometimes fo much fwelled 
and inflamed before the hemorrhagy ap- 
pears, that the original opening will not 
admit of this ; and on proceeding to en- 
large it, fuch eonfulion is met with from. 
effufed coagulated blood between the in- 
terfaces of the mufcles, as well as through 
the whole cellular membrane of the af- 
fected parts, that the divided arteries 
^annot be all brought into view, but by 
fuch extenfive incihons as in this ftate 
of the parts would be attended with more, 
hazard than amputating the limb at a 
proper diftance above : and although it 
is not a common occurrence, yet in- 
ifcances happen where the moft expert fur- 
K 4 geons 



144 Of Compound FraSfures. Ch.XXXIX. 

geons are obliged in this fituation to am- 
putate. 

Mortification is the fecond motive we 
mentioned for amputating in this ftage 
,of compound fractures ; and, when it 
takes place to any confiderable extent, 
it mufl be allowed that it is a very power- 
ful one. We mall have occafion to con- 
iider this fubjecl:, however, more parti- 
cularly when we treat of amputation ; 
and with refpedt to the third caufe we 
mentioned, when the bones do not unite,- 
and when the patient declines under a 
(Copious difcharge of matter, no prac~ti T 
tioner of experience will, in this fitua- 
jtion, difpute the propriety of amputa- 
tion. 

It is this ftate of a compound frac-r 
ture, when the original inflammatory fe^ 
ver excited by the injury is fubfided, 
and before the patient is too much weak- 
ened by the difcharge, which of all others 
we conlider as the mpft favourable for. 
amputation. The exact: time cannot pof- 
fibiy be fixed by any general obferva- 

tion: 



Sect. XV. Of Compound Fraftures. 14/ 

tion : It mud depend upon the particu- 
lar circumftances of every cafe, and 
chiefly upon the quantity of the dis- 
charge, and ftrength of the patient ; and 
thefe again are points which the judge- 
ment of the practitioner in attendance 
can alone decide upon. We may remark, 
however, that as long as the patient doejs 
not feem to be much hurt by the dif- 
charge, however great it may be, the 
operation fhould not be advifed ; for 
while his. ftrength is not much impaired, 
we may with fafety proceed in our en- 
deavours to fave the limb. 

From what has been faid, it will ap- 
pear, that, in private practice, very few 
cafes can occur of compound fractures, 
in which we fhould not attempt to fave 
the limbs. 

In the treatment of compound frac- 
tures, our object is the fame as in the 
management of thofe of the moft fimple 
nature j namely, the replacing of any 
bones that may be deranged, and retain- 
ing them till they are united. 

la 



1 46 Of Compound FraBurcs. Ch. XXXIX. 

In the firft place, all extraneous bo- 
dies mould be removed, as well as all 
thofe fmall pieces of bone that will not 
probably unite with the reft ; for which 
purpofe the opening ihould be enlarged 
with a fcalpel, if it be too fmall to ad- 
mit of their being eafily taken out. And 
this being done, we will in general find 
it an eafy matter to replace the bones if 
we relax all the mufcles of the injured 
limb in the manner pointed out in the 
preceding fedtions of this chapter. There 
is juft one exception occurs to this : A 
iharp point of a bone is, on fome occa- 
fions, fo far pufhed through the tegu- 
ments, that it cannot be replaced by any 
ordinary force ; and to a certain extent, 
the greater the force that is applied to 
it, it is the more firmly fixed between 
the fkin and parts beneath. In fuch cafes 
there are two methods by which the dif- 
ficulty may be removed : By fawing off 
the end of the protruded portion of bone, 
cr enlarging the wound. 

When a \png iharp point of bone is 

much 



SecVXV. Of Compound FraBures. 147 

much protruded, we mould not hefitate 
in removing it ; for although it mould 
be reduced, it would not readily unite 
with the reft of the bone, at the fame 
time that it would be apt to excite much 
pain and irritation. When the portion 
to be taken away is very fmall, it may 
be done with the cutting forceps ufually 
employed in amputations : but when it 
cannot be eafily done in this manner, it 
may with fafety be taken off with a faw ; 
a piece of pafteboard, or of thin fheet- 
lead, being previously inferted between 
it and the teguments beneath. 

But whenever the protruded portion 
of bone is broad at the bafe, and not of 
any considerable length, as there will be 
caufe to hope that it will unite with the reft 
of the bone if they be brought rightly in- 
to contact, we ought certainly to endea- 
vour to fave it ; and in general we will 
be able to do fo by enlarging the opening 
through which it has pafled. If we take 
care to avoid any large blood-vefTels and 
nerves, which thcfe acquainted with the 

anatomy 



X48 Of Compound Trafturcs. Ch.XXXIX. 

anatomy of the parts will readily do, no 
danger will occur from the operation. 
Inftead of adding to the danger of the 
patient, it tends often to leflen it, by re- 
moving a powerful caufe of pain and ir- 
ritation, and thus preventing that inflam- 
matory tenfion to which limbs in this fi- 
tuation are particularly liable. 

To thofe not much accuftomed to treat 
compound fractures in this manner, the 
practice we now recommend may be fup- 
pofed to be attended with hazard j and 
to convert a fmall puncture into an ex- 
tenfive wound, may often appear to be 
cruel and unneceflary. But as the ad- 
miffion of the air has already occafioned 
all the mifchief which can arife from 
this quarter, we do not thus increafe the 
danger of the patient ; and it is general- 
ly well known, that a free incifed wound 
heals more readily than a fmall punc- 
tured one. It is the fkin only which, in 
Bioft cafes, we have to cut here : But 
even where the bone cannot be eafily re- 
duced without carrying the incifion in- 
to 



|'l,.\Ti; l.*5vV 




Sect. XV. Of Compound FraEtuns. 149 

to the fubftance of the contiguous muf- 
cles, we fhould not hefitate in advifing 
it : Only, in this cafe, the opening fhould 
be made as much as poflible in the di- 
rection of the fibres of the mufcles. 

The fplinters of bone, coagulated 
blood, and other extraneous bodies be- 
ing removed, any artery that may be cut 
being fecured with a ligature, and the 
protruded portion of bone replaced, the 
fracture is, in other refpects, to be redu- 
ced in the manner we have advifed when 
fpeaking of fimple fractures ; that is, by 
relaxing the mufcles of the limb, and ex- 
tending the bones no more than is alto- 
gether neceffary. This being done, a 
pledgit of foft lint, fpread with any emol- 
lient ointment, fhould be laid over the 
wound, when the limb fhould be placed 
upon a firm fplint, and flill kept in a re- 
laxed pofture. As it is of much import- 
ance that the wound be regularly drefled 
without moving the limb, it fhould, if 
poflible, be fo placed, that this can be 
done j and with the fame view, the many- 
tailed 



150 Of Compound Fratiures. Ch. XXXIX; 

tailed bandage, in every inftance of 
compound fracture, where it is in any re- 
fpect applicable, mould be preferred to 
the roller. 

As it is a point of the utmoft impor- 
tance to place the limb in fuch a pofture 
as will admit of the fore being drefTed 
without moving it, various inventions 
have been propofed for rendering this in 
every cafe practicable. Very few of thefe, 
however, have anfwered the purpofe for 
which they were intended. The befl I 
have met with is a fracture-box invent- 
ed by the ingenious Mr James Rae of 
this place ; of which, with fome improve^ 
ments made by his fon Mr John Rae, I 
now give a delineation. The leg may 
be laid in it either bent or ftraight, and 
a wound, wherever fltuated, may be dref- 
fed without altering the pofition of the 
limb, as will be more clearly underflood 
from the reprefentation of the instru- 
ment, Plate LXXIII. fig. 3. 

In whatever fituation the limb be pla- 
ced, it is an object of the firft import- 
ance 



Seel. XV. Of 'Compound 'FraBures. I5I 

ance to endeavour to prevent inflamma- 
tion : for when mortification enfues, it 
may be almoft always traced to too great 
a degree of inflammation ; and the fame 
caufe very often gives rife to thofe ex- 
tenfive abfceffes with which fractures of 
this kind are apt to be accompanied. We 
are therefore from the firft to guard 
againft the acceffion of this fymptom ; 
by one or more general blood-lettings, 
proportioned to the ftrength of the pa- 
tient ; by the application of leeches to 
the edges of the fore, when the inflam- 
mation becomes fevere ; by the ufe of 
opiates ; by gentle cooling laxatives ; 
a low regimen ; and other parts of an an- 
tiphlogiftic courfe. The dreflings mould 
be removed once or twice daily, accord- 
ing to the quantity of matter ; and in- 
ftead of dry lint, pltdgits of any emol- 
lient ointment, or Gourland's cerate, will 
be preferable : for I have not found in 
any ftate of thefe fores that ointments 
do harm ; and they always fit eafily, and 

are 



Ij2 Of Compound Tratiures. Ch. XXXlX. 

are more eafily removed than when dry 
lint is applied alone. 

Warm emollient poultices are very 
commonly applied at firft, and continued 
for a good many days : But as they 
prove always troublefome, and cannot be 
removed without in fome degree altering 
the poftare of the limb, I think it better 
to avoid them till we fee whether or not 
they become neceflary by the approach 
of inflammation. In that event they 
mould be immediately employed as the 
iureft means of exciting a difcharge of 
matter : For although we would rather 
wim the fore to heal by what is termed 
the Firft Intention, without the forma- 
tion of matter ; yet this being a very 
unufual occurrence in wounds attending 
compound fractures, and a plentiful dis- 
charge of good pus ^>eing the moft cer- 
tain preventative of mortification, we 
fhould not hefitate in endeavouring to 
promote it whenever a limb with a com- 
pound fracture is attacked with inflam- 
mation. 

As 



Seel. XV. Of 'Compound ' Frafiures. 153 

As foon, however, as our views are ac- 
•compliihed, by the inflammation fubfi- 
ding, and a free difcharge of pus exci- 
ted, the poultices fhould be laid afide : 
for in many inftances, when too long 
continued, they have certainly done 
harm, by relaxing the parts too much, 
and exciting too profufe a difcharge of 
matter. 

When matter is difcharged from a 
compound fracture in too great quan- 
tities, befides laying afide the ufe of 
emollient poultices, we t ought to drefs 
the fore with gentle aftringents, fuch as 
foft lint dipped in a folution of faccha- 
rum faturni ; and the patient mould now 
be fupported with a nourifhing diet, a 
free ufe of wine, Peruvian bark, and 
elixir of vitriol. A free vent fhould be 
procured for the matter ; and when this 
cannot be obtained by putting the limb 
in a proper poflure, it mould be done by 
making a counter opening in a more de- 
pending part. The necemty, however, 
of this may often be prevented by em- 

■Vol. VI. L ' ploying 



154 Of Compound FraSiures. Ch.XXXIX. 

ploying foft lint, or covering the fore 
with foft fponge to abforb the matter, 
and by frequent dreffmgs : for although 
the fores fhould never be more expofed 
to the air than is neceffary, yet when- 
ever the difcharge is copious, there will 
be more rifk from allowing the parts to 
be long immerfed in matter, than from 
the moft frequent renewal of the dref- 
fings. 

When the difcharge from a compound 
fracture becomes excefuve, and cannot 
be lefTened by the means we have men- 
tioned, it will often be found to origi- 
nate from a portion of loofe bone that 
has not been earlier noticed. In fuch 
circumftances, therefore, we fhould al- 
ways examine the fore with as much at- 
tention as poffible ; and wherever a piece 
of loofe bone is difcovered, we ought to 
take it out either at the fore itfelf, or 
by a counter opening if it appears that 
in this manner it can be more eafily 
done. In making an examination for 
this purpofe, the finger alone fhould be 

employed 



Sect. XV. Of Compound FraSlures. 15$ 

employed when the opening is fo large 
as to give it accefs : for in this manner 
we do lefs harm than with a probe ; and 
at the fame time We difcover the real 
ftate of the parts with more precifion. 
When it is neceffary to ufe a probe, it 
fhould be done with caution, for much 
mifchief is frequently done where this; 
inflrument is employed too freely. 

If, inftead of producing a difcharge of 
matter, the inflammation fhould termi- 
nate in gangrene, the fituation of the pa- 
tient becomes ftill more hazardous than 
under the moil extenfive abfceiTes. We 
have elfewhere had occafion to treat of the 
fubject of gangrene ; and we mufl now 
refer to that part of the work *. In a 
following chapter, we ihall have an op- 
portunity of mentioning the period at 
which amputation of limbs, attacked with 
gangrene, mould be advifed. 

In confidering this fubjecl, fome will 

fuppofe that I fhould have given more 

particular directions for fecuring frac- 

L 2 tured 

• Vide Treaiife on Ulcers, &c. Part I. Chap. III. 



156 Of Compound FraStures. Ch. XXXIX. 

tured limbs in ttfreir fituation, efpeeially 
in cafes .of compound fracture : But as I 
know of no method of effecting this 
with fuch certainty and eafe as the one 
I have defcribed, I confider it as unne- 
ceflary even to enumerate the various 
means that have been propofed for this 
purpofe. In particular circumflances, 
thofe we have defcribed in the eleventh 
lection of this chapter, Mr Gooche's ma- 
chine, and Dr Aitken's, may prove ufe- 
ful for keeping the fractured bones ex- 
tended } and much advantage may cer- 
tainly be derived from them in keeping 
the bones fteady when it i& necefTary to 
move a patient wkh a fractured limb 
from one part to another ; but in ordi- 
nary practice, I can without hefitation 
fay, that no advantage is derived from 
any inflrument I have ever known ufed 
for this purpofe. 



CHAF, 



Sect. I. On Luxations. 1 57 



CHAP. XL. 



Of Luxations. 



SECTION I. 

General Remarks on Luxations. 



A Bone is faid to be luxated where 
that part of it forming a joint is 
difplaced. In fome cafes, the end of a 
bone is forced entirely out of the cavity 
where it is naturally lodged: This we 
term a Complete Diflocation. Where 
h 3 any 



1^8 General Remarks Ch. XL. 

any part of the bone refls upon the edge 
of the focket, we fay the Diflocation is 
Incomplete. 

Luxations may with the fame proprie- 
ty as fractures be divided into iimple 
and compound. Where the end of a 
bone is merely difplaced, we term it a 
Simple Luxation ; but where this is ac- 
companied with a correfponding wound 
in the foft parts, laying open the cavity 
of a joint, we fay the Luxation is Com- 
pound. By fome practitioners the term 
Compound is applied to di {locations ac- 
companied with fractures of the conti- 
guous bones, whether the teguments be 
injured or not. We fay with more pro- 
priety, however, that a luxation in fach 
circumftances is of a Complicated Na- 
ture. 

For the moil part luxations are pro- 
duced by external violence, and appear 
as the immediate confequences of fome 
confiderable force applied to the injured 
parts. They are particularly apt" to oc- 
cur in leaping and falling, from blows, 

and 



Sect. I. on Luxations. 159 

and violent twifts and diffractions of the 
different bones of a limb : But they are al- 
fo produced by other caufes ; by a mor- 
bid weaknefs or relaxation of the liga- 
ments and mufcles of a joint, which 
fbmetimes occur as the confequences of 
palfy and long-continued rheumatic af- 
fections ; and by the end of a bone be- 
ing pufhed from the cavity in which it 
was lodged, by matter collected in it, 
or by farcomatous tumors and exoflofes. 

Thofe cafes of diflocation that occur 
from external violence, are chiefly the 
objects of furgery. The fymptoms ufual- 
4y induced by thefe, are, inability to 
move the injured limb ; pain, tenfion, 
and deformity in the part affected ; and 
in fome cafes inflammation, fubfultus, 
tendinum, and fever. 

In general, the motion of the limb is 
impaired in proportion to the extent of 
the luxation ; but in fome cafes, even the 
mod partial affection of this kind ren- 
ders the joint perfectly ftifF and immove- 
able, and creates the mofl exquifite pain 
h 4 0« 



160 General Remarks Ch, XL. 

on every attempt to move it. This is 
particularly the cafe in partial diflcca- 
tions of all the large joints. 

The deformed or altered appearance 
of a joint, with which a luxation is al- 
ways accompanied, muft necefTarily be 
in proportion to the extent of the injury • 
but this is not the cafe with the other 
fymptoms we have mentioned : for fub- 
fultus tendinum, inflammation, and fever, 
are often excited to a greater height by 
partial diflocations, where the ends of 
tones are not much moved from their 
natural fituations, than where they are 
altogether forced from their fockets, . 
owing to a circumflance which we fhall 
prefently endeavour to explain. 

The firft approach of fwelling in cafes 
of diflocation, is always of the inflamma- 
tory kind, and is a neceifary effect of 
the violence done to the injured parts. 
This, however, fhould be diftinguifhed 
from a fecondary fwelling to which thefe 
affections are liable, an extenfive tume- 
faction which in fome cafes fpreads over 

all 



Sed. I. on Luxations. 161 

all the under part of the limb, and which 
feems to originate from a different caufe. 
Inftead of being red, tenfe, and painful, 
'the teguments are pale, foft, and cedema- 
tous ; owing, I fuppofe, to the lymphatic 
veiTels of the limb being comprelled by 
the end of the difplaced bone. Swellings 
of this kind are mod frequent in dislo- 
cations of the humerus and femur ; in 
which alfo confiderable numbnefs or di- 
minilhed fenlibility is apt to be excited 
by the compreffion of the nerves of the 
limb. 

It is of much importance to diftinguifh 
diilocations from other affections of the 
joints, and to afcertain to what extent 
the bones are moved from their fitua- 
tions. In compound luxations the na- 
ture of the injury is obvious ; and for the 
mofl part it is fufficiently evident in cafes 
where bones are completely diflocated ; 
but partial diflocations are often not tq 
be difcovered but by the mofl minute 
examination: They therefore frequent- 
ly pafs unnoticed, or are confidered as 

fprains 



1 62 General Remarks Ch.XL. 

fprains and contufions ; and thus, in cafes 
where complete cures might be perform- 
ed by due attention on the part of the 
practitioner, patients are often rendered 
lame and miferable for life. 

The fymptoms enumerated above are 
common to all diflocations. In fpeaking 
of particular luxations, we fhall have oc- 
cafion to mention the peculiarities of each, 
and fhall endeavour to do it in fuch a man- 
ner as may with moft certainty prevent 
fuch unfortunate occurrences as we al- 
lude to. 

In forming a prognofis of the event of 
luxations, that is, of the practicability 
of reducing them, and of the termina- 
tion of the fymptoms with which they 
are attended, various circumftances re- 
quire attention : The form and ftructure 
of the different joints j the nature and 
extent of the luxation, together with the 
degree of violence by which it was pro- 
duced, and the circumftances with which 
it may be complicated ; and laftly, the 
duration of the injury. 

The 



Seel. I. on Luxations. 163 

The fkeleton is commonly had re- 
courfe to for a knowledge of the joints ; 
but although it is proper that every ftu- 
dent mould be acquainted with the ar- 
ticulations in a dry flate, we mould by 
no means reft fatisfied with this. In the 
treatment of luxations, it is equally ne- 
ceffary that we have an exact knowledge 
of the joints in a recent ftate ; of the 
cartilages, ligaments, and tendons, with 
which the bones are connected, as well 
as of the contiguous parts in which the 
heads of the difplaced bones may happen 
to be lodged : Otherwife our ideas of 
the nature of thefe injuries, and of the 
means that will moft probably prove fuc- 
cefsful in the treatment of them, mult be 
very imperfect. 

We cannot enter upon a minute de- 
fcription of every joint, as it would lead 
to an extent of difcuffion incontinent 
with the nature of this work. Refer- 
ring to the proper fources for more par- 
ticular information, we (hall here only 
pbferve, that it is chiefly thofe joints 

that 



1 64 General Remarks Ch. XL. 

that are poffefTed of much motion in 
which we meet with luxations. Of thefe, 
there are two varieties. The one term- 
ed the Junction by Ball and Socket, 
where the head or end of one bone is 
received into the cavity of another ; and 
the other termed by anatomifts Gingli- 
mus, or the Hinge-like Joint, from its 
refembiance to the hinge of a door. In 
this the joint is formed by different parts 
of one bone being received into cavities 
or indentations of another. The former 
admits of the mod extenfive motion, as 
is exemplified in the joint of the hume- 
rus with the fcapula, and in that of the 
femur with the ofla innominata; while 
the latter does not admit of more than 
that of flexion and extension, as is the 
cafe in the elbow and knee. In thefe we 
accordingly find, that this more limited 
motion to which they are confined, ren- 
ders them lefs liable to luxations ; while 
the free motion of the others expofes 
them to frequent injuries of this kind, 
as is more particularly the cafe in the 

joint 



Seel. I. en Luxations '. 1 65 

joint of the humerus, from the cavity in 
which the head of that bone is lodged be- 
ing of no great depth. 

Befides the ufual coverings of tegu- 
ments, mufcles, and tendons, in common 
to joints with the reft of the body, every 
joint poffefTed of much motion is provided 
with what we commonly term a Capfular 
Ligament ; which is a firm fbmewhat ela- 
ftic fubftance, forming a kind of pouch 
or bag, which completely furrounds the 
articulation, and ferves at the fame time 
to retain the ends of the bones together, 
and to contain a thin transparent fluid, 
the fynovia, for the purpofe of lubrica- 
ting the cartilages which cover the ends 
of the bones. 

Practitioners are not agreed whether 
in cafes of luxation the capfular liga- 
ments are ruptured or not. As it has 
appeared on direction, in a few inflances, 
that the ligament was ruptured, forne 
have concluded that it is the cafe in all ; 
while others are of opinion, that the li- 
gament always remains entire, except 

where 



1 66 General Remarks Cli. XL, 

where the luxation has been the confe- 
quence of very fevere and unufual de- 1 
grees of violence. 

The remit of my obfervation on this 
point is, that partial luxations may hap-^ 
pen without any rupture of the capfular 
ligament ; but that it is always ruptured 
in complete luxations produced by ex- 
ternal violence ; nay, that it is often ate 
mod entirely tore from its infertion 
round the neck of the bone. Where the 
head of a bone is gradually pufhed from 
its focket by the flow formation of a tu- 
mor within the joint, and where the li- 
gament is perhaps much relaxed by dif- 
eafe, a luxation may no doubt happen 
without either rupture or laceration : 
but we cannot fuppofe that fuch a firm 
fubftance as a ligament is in a ftate of 
health, will yield, without burfting,*to 
the fiidden impulfe produced by the com- 
plete diflocation of the head of a bone, 
and where the difplaced bone is in fome 
cafes almoft inftantaneouily forced to 
the diftance of feveral inches from its- 
natural 



Seel. I. on Luxations. l6j 

natural fituation. Different inftances 
are upon record of this opinion being 
fupported by the diffeclion of diflocated 
joints after death ; and were it neceffa- 
ry, I could add others that have fallen 
within my own obfervation. 

We mentioned above, that the pain at- 
tending partial diflocations is commonly 
very fevere on any attempt being made 
to move the joints. For the moft part, 
indeed, it is more exquifite than it ufual- 
ly is where the luxation is complete ; and 
we conclude that it proceeds from the 
capfular ligament being overftretched, 
and from the ends of the difplaced bones 
continuing to act againft it inftead of 
pafTing freely through it. 

In judging of a luxation, the diflance 
to which the head of the difplaced bone 
is forced, and the degree of violence by 
which it was produced, require particu- 
lar attention. Where a bone is only 
partially diflocated, although the pain 
attending it may be very acute, yet the 
redudion of it will be accomplished both 

with 



168 General Remarks Ch, XL; 

with more cafe and certainty than if the 
fame bone had been forced completely 
out of its fituation. And where the joint 
has not fuffered any extraordinary vio- 
lence, the inflammation and other con- 
comitant fymptoms will not prove fo for- 
midable as they commonly do where the 
capfular ligament and other foft parts 
have been much ftretched, or otherwife 
feverely injured. 

One of the moil unfavourable cireum- 
flances with which a luxation is ever at- 
tended, is a fracture of one or both of 
the bones concerned in it. Even a frac- 
ture of the difplaced bone is always a 
difagreeable occurrence, and this efpe- 
cially if it be broke near to its neck, as 
in this cafe it can fcarcely be laid hold 
of for the purpofe of reducing it; but 
the riik attending it is much more con- 
fiderable when the bone forming the 
fbcket into which it mould be received 
is alfo broke : for we know from expe- 
rience, that fractures of thefe parts are 
more apt to be attended with fevere de- 
grees 



Sect. I. on Luxations. 169/ 

grees of inflammation, as well as with 
extenfive fuppurations, than fractures of 
any of the long bones. And when the 
focket is broke, there is always much 
hazard of the joint being rendered flifF 
for life, even when the reduction of the 
difplaced bone is accomplimed in the ea~ 
fieft manner. 

A diflocatiori being more or lefs re- 
cent, is the next point requiring our at- 
tention : for we know that luxated bones 
are, czeteris paribus, more eafiiy reduced 
foon after they are difplaced than when 
much time has elapfed. While the in- 
jury is recent, the bone will neceffarily 
pafs with more eafe along the parts which 
it has juft traverfed, than it poflibly can 
do after lodging feveral weeks or months 
among the contiguous mufcles ; where 
the head of it, inftead of being loofe, as 
is ufually the cafe at firft, will have form- 
ed a focket for itfelf, and will probably 
be firmly grafped by fome of thofe muf- 
cular fibres which more immediately fur- 
round it. At this period too, the cavity 

Vol. VI. M froja 



170 



General Remarks Ch.XL. 



from whence it was diflodged may pro- 
bably be in fome degree filled up by the 
contiguous foft parts : Not that /the fy- 
novia ever becomes infpiflated, fo as to 
produce this effect ; for although this 
has by many been fuppofed to happen, 
and various means have been propofed 
for preventing and removing it, yet we 
now know that the opinion is ill-found- 
ed. No infpiffation of this fluid has ever 
been difcovered by diflection, although 
flifF joints, where this ftate of the fyno- 
via was previoufly confidered as the 
caufe, have often been laid open for the 
purpofe of detecting it. But although 
the cavity of a joint may not be filled 
tip in confequence of any particular af- 
fection of the fynovia, there is much rea- 
ibn to fuppofe that in courfe of time it 
will be diminifhed by the conflant ac- 
tion of the contiguous mufcles ; which 
will not only force the cellular fubftance, 
fat, and other fbft parts with which it k 
covered, into it, but may even have 
fome effect in comprefling the bone it- 

felf, 



Sect. I. on Luxations. l*]\ 

felf, or the cartilaginous brim with which 
the bone is ufually covered. 

Thefe are the circumftances in diflo- 
cations which more particularly require 
attention j but we have alfo to remark, 
that the patient's age and general ftate 
of health, influence the reduction of a 
diflocated bone. Diflocations are more 
eafily reduced at fome ages and in parti- 
cular habits of body, than in others* 
Thus, in advanced periods of life, and in 
weak delicate conftitutions, where the 
mufcles give little refiftance, difplaced 
bones are more eafily moved than in the 
vigour of youth and in robuft habits of 
body, where the fuperior flrength of the 
mufcles has a confiderable efFect in pre- 
venting it. 

In the treatment of diflocations, the 
objects we have in view are, to put the 
bone that is difplaced into its natural fi- 
tuation, with as much eafe and expedi- 
tion as the nature of the cafe will per- 
mit ; to retain it in this fituation till the 
injured parts have recovered their tone ; 
M 2 and 



7 -j 2 - General Remarks Ch.XL. 

'and to obviate pain, inflammation, and 
any other fymptom that requires atten- 
tion. 

Before proceeding to the reduction of 
a diilocation, we fhonld examine the con- 
tiguous foft parts", to iee whether they be 
in a fit fituation for it or not : for al- 
though the fooner the operation is at- 
tempted, the more certain we will in ge- 
neral be of fueceeding ; yet whenever the 
furrounding teguments and mufcles are 
much contufed and inflamed, it is better 
to allow the pain and fwelling that takes 
place to fubiide before any trial is made 
fbr reducing the bone ; at leaft I have 
always been in the practice of this. I 
never obferved any bad confequences en- 
fue from it ; and I have known much 
mifchief done by a limb being much 
ftretched while the parts furrounding a 
diflocated joint have been in an inflamed 
ftate. 

In fuch circumstances, therefore, we 
ihould endeavour, by local blood-letting 
with leeches, by the ufe of faturnine ap- 
plications, 



Sect. I. on Luxations. 173 

plications, by a low regimen, and put- 
ting the limb in an eafy relaxed pofture, 
to remove the inflammation before any 
attempt is made for reducing the bone. 

In almolt every diflocation it is one 
bone only that is difplaced, the other 
bone or bones of which the joint is form- 
ed remaining in their natural fituation ; 
and it will be found perhaps univerfally, 
that it is the bone connected with the 
inferior part of a limb that is forced from 
its fituation ; the bone forming the upper 
part of the joint, if it be not fractured, 
being feldom in any refpect altered : In 
the reduction therefore of a luxation, the 
-only attention we have to give to the 
upper part of a limb, is to keep it firm 
and fteady, while we endeavour by the 
eafieft and moft effectual means to re*» 
place the under part of it. 

A perfon not acquainted with anato- 
my, might be led to fuppofe that this 
may always be readily accomplifhed ; as 
he will be apt to conclude, that the fame 
degree of force which pufhed a bone out 
M 3 of 



j 74 General Remarks Ch. XL. 

of its place, will with equal eafe replace 
it. This would no doubt be the cafe, 
were it the bane only that we had to act 
upon, or if it was merely connected with 
inorganic matter that would not give 
any refiftance to the means employed to 
reduce it : But every joint being either 
partly furrounded by, or much connected 
with, mufcles, the contractile power with 
which they are endowed acts with much 
force and advantage againfl every attempt 
that is made for the reduction of the bone ; 
for they not only draw it beyond the end 
of the contiguous bone againfl which it 
ought to be placed, but they often pull 
it out of its natural direction, and fix it 
firmly in fome neighbouring cavity, from 
whence it is diflodged with difficulty; 
while the flimulus created by every trial 
we make for replacing the bone, is apt 
to excite a further exertion of the muf- 
cles, and increafes the difficulty which 
accompanies the reduction. 

It is therefore obvious, that in the re- 
duction of every dillocated bone, the rnuf- 

cles, 



Sect. I. on Luxations. 175 

cles with which it is connected mould be 
put as much as poflible into a ftate of 
relaxation ; for in this fituation, the re- 
fiftance they give to the force employed 
for moving the bone is inconfiderable, 
when compared with what is required 
for the fame purpofe when they are kept 
in a ftate of extenfion. In the one, it is 
ufually done with eafe, both to the pa- 
tient and furgeon ; while in the other, 
that is, while a limb is much flretched 
or extended, it is with the utmoft diffK 
culty that a diflocated bone can be mo- 
ved. 

By relaxing all the mufcles of a limb, 
we may in general obtain as much force 
as is requifite for reducing a luxation 
merely from afTiftants ; but in fome in- 
ftances more is required than can be ap- 
plied in this manner : In fuch cafes, vari- 
ous inftruments have been propofed for 
increafing our powers of extenfion ; fome 
of which, and perhaps the moft ufeful, 
are delineated in Plates LXXVII. and 
LXXVIII. 

M 4 But 



I76 General Remarks Ch. XL, 

But whether we find it neceflary to 
life machines of this kind or not, no 
more force mould be ever employed than 
is juft requifite ; and it ought always tQ 
be applied in a flow gradual way, by 
which there is much lefs riik of any 
harm being done, than when the mufcles 
of a limb are forcibly and fuddenly 
flretched: And it will alfo be under, 
flood, that the whole force ufed for the 
reduction of a diflocated one, fhould be 
applied to that bone only, and not to any 
other part of the limb. 

Befides the refiflance arifing from the 
acl-on of the mufcles, we fometimes meet 
with a good deal of difficulty from the 
projecting end of a diflocated bone hav-r 
ing paHed that of the contiguous bone, 
In this cafe the extenfion is to be made 
in fuch a direction as will belt obviate 
this occurrence. 

In extending a limb for the purpofe of 
reducing a diflocation, it is abfolutely 
neceflary to carry the extenfion fo far as 
tp diflodge the difplaced bone, and to 

bring 



Sect. I. en Luxations. 1 77 

bring the end of it on a line with the 
end of the other to which it is to be 
oppofed, otherwife no advantage will be 
gained by the operation ; for while any 
part of one bone projects paft the extre-* 
jnity of the other, no means we can em*- 
ploy will be able to replace it, unlefs a 
fufficient force be applied to it, as has 
fometimes happened, for breaking off the 
projecting part ; while, on the contrary, 
the reduction is always accomplifhed in 
the eafieft manner, as foon as the dis- 
placed bone is drawn freely paft all the 
projecting parts of the other : nay, when 
the end of a difplaced bone is brought 
to this fituation, it would be difficult to 
prevent it from paffing inftantaneoufly 
into the fituation where it is naturally 
lodged. So that in the reduction of dis- 
locations, our chief object is to make 3. 
fufficient degree of extenfion in the ear 
fieft manner, when the ordinary action 
of the mufcles will for the moft part 
replace the bone : Or when this fails, the 

moft 



X jB General Remarks Ch. XL. 

nioft gentle preffure will be fufficient for 
the purpofe. 

The diflocated bone being reduced, 
there is feldom any difficulty in retain- 
ing it in its fituation, inilefs it has often 
been difplaced before : The fureft means 
of effecting it, is by putting the limb in- 
to a relaxed pofture, and fupporting the 
bone that has been juft replaced with a 
proper bandage, till the unrounding foft 
parts have recovered their natural tone. 

The fymptoms that prove moft urgent 
in diflocations, both before and after the 
bones have been reduced, are, pain, in- 
flammation, and fwelling. For the moft 
part they abate after the reduction is com- 
pleted ; but while any degree of inflam- 
mation continues, repeated applications 
of leeches fhould be advifed as the moft 
effectual remedy : and as this fymptom 
is to be confidered as the caufe of all the 
others, as well as of thofe chronic pains 
which joints are liable to that have ever 
been diflocated, it requires particular at- 
tention. But having confidered this fub- 

jea 



SedV. I. on Luxations* X79 

je6l very fully when treating of contu- 
fions, we muft refer to Chap. XXXVII. 
Section II. § 2. for what was then fkid 
upon it. 

In the firfl part of this fection, we have 
faid that luxations are fometimes com- 
bined with fractures of the difplaced 
bones. When a bone is fractured at a 
considerable diftance from the luxated 
joint, we may for the mod part be able 
to reduce the luxation immediately, when 
the fracture mould be treated in the 
ufual way : But when a bone is fractured 
fo near to the luxation that it cannot be 
laid hold of, the cafe is thereby rendered 
both difficult and uncertain. In the fmal- 
ler joints, as in thofe of the fingers and 
toes, the difplaced portion of bone may 
in fome inftances be puflied into its fitu- 
ation ; but in all the larger joints, parti- 
cularly in the hip-joint, and in that of 
the fhoulder, we muft firft allow the frac- 
ture to heal, and the union of the frac- 
tured bones to be perfectly firm, before 
we attempt to reduce the luxation. 

In 



2 So General Remarks Ch. XL. 

In. compound luxations, that is, where 
ioints are not only luxated but laid open 
by external injuries, the treatment we 
have advifed in compound fractures will 
prove equally applicable. Indeed the 
nature of thefe affections is fo fimilar, 
that almoft all the obfervations made 
upon the one will apply with nearly 
equal propriety to the other : fo that at 
prefent we Ihall refer to Section XV. of 
the laft Chapter, where the fubject was 
particularly confidered. 

We may juft fhortly obferve, that af- 
ter the luxated bones are replaced, and 
the limb laid in a proper pofture, our 
next object is to prevent inflammation j 
which we do with moft certainty by co- 
pious blood-letting with leeches applied 
as near as poffible to the injured parts ; 
drefling the fores with Goulard's cerate, 
or any other mild ointment ; moderating 
the pain with adequate dofes of opiates ; 
and a low regimen. 

This being done, we have to endeavour 
to prevent any matter from lodging a-* 

bout 



Sect. I. on Luxations. 1 S r 

bout the joint, by placing the limb in 
fuch a manner as will not readily allow 
it to run off: if this fails, by drefling the 
fore more frequently, and abforbing the 
matter with a bit of fponge ; or, when the 
quantity of matter is cOnnderable, by a 
counter opening made in a depending 
fituation. 

When mortification takes place, it is 
to be treated in the manner we have ad- 
vifed, when fpeaking of this fubject in a 
former publication *. 

All that we have hitherto faid relates 
in general to luxations produced by ex- 
ternal violence. When they proceed from 
the heads of bones being pufhed from 
their fockets, either by tumors of a flelhy 
or ofTeous nature, or by collections of 
matter, they may almoft in every inftahce 
be confidered as incurable: When the 
joint is fo fituated that the difeafed parts 
can all be removed, this meafure mould 
be advifed ; but when this cannot be com- 
pletely 

* Treatife on the Theory and Management of UI- 
cm, &c. Part I. Seftion III. 



1 82 General Remarks Ch. XL. 

pletely effected, all that art fhould at- 
tempt is, to give as free a difcharge as 
pomble to any matter that may form, 
and to fupport the conftitution with a 
proper diet, to prevent it from being too 
much reduced by the difcharge. 

Diflocations are fometimes the confe- 
quence of too great a relaxation of the 
ligaments and tendons which ferve to 
connect the bones in a healthy flate. 
This relaxation is feldom fo completely 
removed as to prevent the bones from 
falling out from time to time : but the 
inconveniency may be in fome meafure 
obviated by fupporting the limb with a 
proper bandage ; by endeavouring to re- 
ftore the tone of the relaxed parts by 
cold bathing ; and, in fome inftances, 
electricity has appeared to prove ufe- 

ful. 

We mall now proceed to fpeak of dif- 
locations from external violence as they 
occur in particular parts. 



SECTION 



Sect. II. On Luxations i &c. 1 83 



SECTION II. 



Of Luxations of the Bones of the Cranium. 



TH E bones of the cranium are fre- 
quently feparated from each other 
at the futures in cafes of hydrocephalus 
internus. This, however, can feldom 
become an object of furgery. If the 
collection is removed either by the ufe 
of medicines, or by an operation, all that 
art can do farther is to fupport the parts 
with a proper bandage. 

We alfo find in fome inftances, that 
openings are produced at the futures by 
external violence, particularly by falls 
from great heights. Accidents of this 
kind, however, very commonly prove 
fatal. I have only met with one inftance 
of a patient under fuch circumftances re- 
covering. 



184 Of Luxations of the Ch. XL, 

covering. All that can with propriety 
be done, is to fupport the parts by gentle 
regular preflure with a proper bandage ; 
to prefcribe blood-letting and other re- 
medies, according to the violence of the 
fymptoms ; and to keep the patient quiet 
and confined to a proper pofture during 
the cure. 



SECTION III. 

Of Luxations of the Bones of the Nofe. 



TH E bones of the nofe are fo firmly 
united, and they ferve fo effectually 
to fupport each other, that they are fel- 
dom diflocated. Inftances of it, however, 
are fometimes met with. 

As thefe bones are only thinly co- 
vered with foft parts, luxations in any 
part of the nofe are eafilv difcovered 

by 



8ed. lit. Bones of the Ncfe. 185" 

by the touch, as well as by the defor- 
mity which they occafion. 

In the reduction of a luxation of thefe 
bones, the patient mould be feated op- 
pofite to a proper light, with an afTiftant 
behind fupporting his head : and the fur- 
geon Handing before, mould endeavour 
to replace the bones with as much exact- 
Uefs as pofTible. In general this will be 
practicable with the fingers alone; but 
when one of the bones is pufhed inwards, 
it will be more eafily accomplifhed by 
pufhing one of the tubes in Plate XLIII. 
fig. 2. up the correfponding noftril, in 
Order to elevate the deprefTed piece ; and 
if the tube be guarded with fome plies 
of foft lint, it may be retained in its fi- 
tuation till there is no longer any rifk of 
the bone flipping out. 

When either of the bones of the nofe 
is pufhed outwards, it muft firft be exact- 
ly replaced, and afterwards retained in 
us fituation by a proper application ' of . 
a double-headed roller. 

Vol. VI. , N SEC- 



iSG Of Luxations of the Ch.XL* 



SECTION IV. 



Of Luxations of the Lower Jaw. 



THE lower jaw is connected by a piece 
of very beautiful mechanifm with 
the bones of the head. There is in each, 
temporal bone an irregular oblong cavi- 
ty, immediately before the external me- 
atus auditorius. In thefe cavities, the 
two condyles of the lower jaw are lodged ; 
and by means of two intermediate loofc 
cartilages which move along with the 
condyles, and which correfpond with the 
irregular furfaces of the cavities in which 
they are placed, fuch a degree of firm- 
nefs is given to this joint as would other- 
wife be inconfifhent with the freedom of 
motion of which it is pollened ; for al- 
though the condyles of the jaw are fe- 

cured 



Sea.IV. Lower Jaw. I #7 

cured by different ligaments, as well as 
by ftrong mufcles, to their fituations, par- 
ticularly by the ftrong tendons of the 
temporal mufcles inferted into the co- 
ronoid procefTes of the jaw ; yet the varie- 
ty of motions which the under jaw is 
conftantly performing, would render it 
very liable to diflocations y were it not for 
the intervention of thefe moveable car- 
tilages, which admit of every necefTary 
freedom ; while fuch a loofe, extenfive 
motion is prevented, as muft have hap- 
pened if the heads of the condyles had 
been placed in large fmooth cavities 
without thefe cartilages between them. 

The under jaw cannot be diflocated 
either upwards, backwards, or laterally ; 
it can only be diflocated forward and 
downward. In every other direction, the 
condyles are fo much furrounded with- 
bone, that they cannot be forced out of 
their correfponding cavities, as will be 
readily feen on an examination of the 
fkeleton : But when the mouth is widely 
opened, as happens in yawning, the con- 
N 2 dyl§* 



1 8 8 Of Luxations of the Ch.XL. 

dyles are apt to flip too far over the an- 
terior boundaries of thefe cavities. In 
this manner a diflocation takes place, as 
we difcover by the chin being thrown 
forward and downward, while the mouth 
remains open, at the fame time that much 
pain is produced by every attempt to clofe 
it ; nor can the patient fpeak diftinctly, 
or fwallow but with much difficulty. 

In fome cafes one fide only of the jaw 
is diflocated, that is, one of the condyles 
remains nearly in its natural fituation, 
while the other is thrown entirely out. 
In this cafe, the jaw, inflead of falling 
directly down, is pufhed downwards, and 
fomewhat towards the fide oppofite to 
that in which it is diflocated. 

Befides the fymptoms we have men- 
tioned of pain on any attempt to clofe 
the mouth, and of 'difficulty in" fpeaking 
and fwallowing, we are told by all the 
ancient writers on this fubject, and by 
all thofe who have copied from them, 
that luxations of the jaw are apt to in- 
duce convulfions, and even death. I 

have- 



Sect. IV. Lower Jaw. 189 

have never, however, met with an in- 
ftance of this, nor is it probable that it 
will ever happen, unlefs from great mis- 
management on the part of the furgeon. 

A luxation of the jaw being very dif- 
treffing, and even alarming to thofe not 
acquainted with the real nature of it, 
immediate affiftance is commonly de- 
fired ; and with due attention we can Sel- 
dom fail in reducing it. » 

The patient being firmly feated on a 
low chair, with his head properly Sup- 
ported behind, the furgeon (landing be- 
fore, with his thumbs Sufficiently guard- 
ed, mould pufh them as far as they will 
go between the teeth of the upper and 
under jaws, the under or flat part of 
the thumbs being applied to the teeth of 
the under jaw : the palm of each hand 
mould be applied to the outfide, while 
with his fingers he lays a firm hold of 
the angles of each jaw. With the fin- 
gers applied in this manner, he mould 
pull the under jaw forward till he finds 
it move fomewhat from its fituation : and 
N 3 &» 



190 Of Luxations of the Ch. XL. 

this being done, but not till then, he 
fhould prefs the jaw forcibly down with 
his thumbs, and moderately backwards 
xAxh the palms of his hands ; when, if 
the different parts of the operation be 
rightly managed, the ends of the bone 
will immediately flip into their fitua- 
tion ; upon which the thumbs fhould be 
inftantly withdrawn. 

In general, we are directed to prefs the 
jaw downwards and backwards : but al- 
though this might fucceed in fome inftan- 
ces where the jaw is diflpcated only on 
one fide, yet even there it would often 
fail ; and it would feldom anfwer when 
both condyles are out : For till they be 
quite difengaged from the bones on which 
they reft, and which they can only be by 
pulling the jaw forward, all the force 
we can employ in pulling them down 
will be of little avail, as I have 1 feen in 
different inftances. 

I have defired, in prefhng down the 
jaw, that at the fame time it fhould 
be preffcd moderately backwards : The 

flighteft 



Sect. IV. Lower Jaw. 191 

flighted force, however, in this direction, 
will be fufficient^ nay, in fome cafes 
it will not be found necefTary : for as 
foon as the condyles are fufficiently de- 
prefled, they are almofl inflantaneoufly 
drawn into their natural lituations by 
the ordinary action of the temporal muf- 
cles, whether any force be applied for 
this purpofe or not. 

The treatment we have advifed an- 
fwers equally well, whether the jaw be 
luxated on one fide, or on both ; but 
where one condyle only is thrown out, 
the force ufed for depreffing the jaw 
mould be chiefly applied to that fide. 

A luxated jaw being reduced, the pa- 
tient mould be advifed to avoid every 
caufe that might have any effect, in 
throwing the bone out again; parties 
lary much fpeaking, gaping, and yawn- 
ing, as the condyles are apt for a consi- 
derable time to be turned out by any of 
thefe. 

In the reduction of a diflocated jaw, 

the thumbs are very apt to be bit if they 

N 4 br 



I93 Of Luxations Ch. XL. 

be not well protected, or if they be not 
inftantly withdrawn on the bones flip- 
ping into their fituations. For the moft 
part the end of a handkerchief is wrap- 
ped round them ; but a covering of firm 
leather anfwers better, or a cafe of thin 
iron covered with leather, would be flill 
preferable, as it would not occupy fo 
much fpace. It would pafs farther into 
the mouth, and would thus act with 
more Advantage in forcing down the 
jaw. 



SECTION V. 



Of Luxations of the Head. 



THE head is connected in fuch a man- 
ner: with the atlas or firft vertebra 
of the neck, that it moves upon it with 
eafe and freedom backwards and for- 
wards, 



Secl.V. of the Head. J93 

wards, the two condyles of the cs occi- 
pitis being received into corresponding 
cavities in the fuperior oblique procefles 
of that bone : But the lateral and rota- 
tory motion of the head proceeds froni 
the immediate connection between the 
head and fecond vertebra of the neck 
by means of the proceffus dentatus of 
that bone ; which pairing through the 
back part of the large cavity of the at- 
las, is fixed by means of different liga- ■ 
ments to the os occipitis. 

The connection between the head and 
the firfl of thefe bones is fo firm, that it 
is not probable they are ever feparated ; 
at leaft I have not heard of any inflance 
of this being difcovered on diffection. 
It rather appears that in luxations of 
the head the connection is deflroyed be- 
tween the head and the fecond vertebra, 
the head being forced with fuch violence 
forward as to ftretch or rupture the li- 
gaments by which the tooth-like procefs 
of this bone is fixed to the occiput : : at 
leaft this has been found to be the cafe 

in 



194 Of Luxations Ch. XL. 

in different inftances of thefe difloca- 
tions ; and it has been commonly obfer- 
ved in people who have fuffered by hang- 
ing. 

In every diflocation of the head, the 
head falls forward upon the breaft ; the 
patient is inftantly deprived of fenfibili- 
ty ; he lies as if he were dead ; and foon 
dies if the luxation be not quickly re- 
duced. Injuries of this kind are produ- 
ced mod frequently by falls from great 
heights or from horfeback. 

Luxations of the head for the molt 
part terminate fatally ; but as feveral 
inftances have occurred where this has 
been prevented when timecus affiftance 
has been given, we have reafon to fup- 
pofe that recoveries from this accident 
would be more frequent if this could be 
always procured. 

Different means have been propofed 
for the reduction of thefe luxations ; but 
every thing requiring much preparation 
is here inadmiflible. In all fuch cafes, 
our views muft be inftantly carried into 
execution j and it fortunately happens, 

\ that 



Sect. V. of the Head. 1 95 

that in perhaps every inftance they may 
be accomplished without any prepara- 
tion. 

The patient being feated upon the 
ground and fupported by an afliftant, the 
furgeon Handing behind fhould raife the 
head from the breaft ; and the afliftant 
being defired to prefs down the moulders, 
the head fhould be gradually pulled 
flraight up till the diflocation is reduced ; 
or if this does not happen with moderate 
extenfion, it may at the fame time be 
gently moved from fide to fide. A fud- 
den crack or noife is heard on the reduc- 
tion being completed ; and if the patient 
be not entirely dead, it is immediately 
afcertained by a partial recovery of all 
his faculties. In fome cafes they have 
been completely reftored on the head be- 
ing replaced ; but in others they have 
remained long impaired, and in fome 
have always continued fo. 

The reduction being effected, the pa- 
tient fhould be immediately laid in bed. 
His head fhould be kept elevated, and re- 
tained 



196 Of Luxations of the Ch. XL. 

tained by a proper bandage for a confi- 
derable time in one pofture. And with 
a view to prevent inflammation, blood- 
letting mould be prefcribed in fuch quan- 
tities as the patient can eafily bear j his 
bowels mould be opened with proper 
laxatives ; and he fhould be confined to 
a low regimen. 



SECTION VI. 



Of Luxations of the Spine , Os Sacrum , andOs 
Coccyx, 



'HP HE vertebrae or bones of which the 
fpine is compofed, are fo intimately 
connected by the proceffes of one bone 
running into correfponding parts of ano- 
ther, as well as by ftrorig ligaments and 
mufcles, that they are very feldom dif- 
located. They are fo firmly united in- 
deed. 



Sea. VI. Spine, Os Sacrum, &c. 197 

deed, that I do not fuppofe that any of 
them can be diflocated by external vio- 
lence without being fractured. Befides 
the means of connection we have men- 
tioned, the vertebra: of the back are much 
ftrengthened by the fupport they receive 
from the ribs. 

I never met with a complete difloca- 
tion of any of the vertebrae ; nor do I 
fuppofe that it ever happens, even when 
accompanied with a fracture, without 
producing immediate death : for the force 
neceflary to move one of the vertebral 
from its fituation, would not only be at- 
tended with the compremon, but even 
with the laceration, of the fpinal mar- 
row, while the contents of the thorax or 
abdomen would be efTentially injured. 
I do not fuppofe, therefore, that a com- 
plete diflocation of any of thefe bones 
can ever become an objeifl of furgery. 

We know, however, that one or more 
of the vertebrae may be partially diflo- 
cated, and that the patient may furvive 
for a confiderable time. In fome cafes, 
perhaps, complete cures may be obtain- 
ed ; 



tgB Of Luxations of the Ch. XL. 

ed ; but I believe thefe will not be fre- 
quent. 

Thefe luxations are ufually produced 
by falls from great heights, or by vio* 
lent blows, or by the pafling of heavy 
weights over the body. 

They are diftinguifhed by the body 
being diftorted, by examination with 
the fingers, and by the fymptoms which 
they induce ; which are fuch as ufually 
occur from compreflion of the fpinal 
marrow ; particularly a paralyfis of all 
that part of the body lying beneath the 
injured part, and either a total fuppref- 
fion of urine, or an involuntary pamng a 
of both urine and feces. 

There is reafon to fuppofe, from the 
mechanifm of the parts, that the verte- 
brae will feldom or never be diflocated 
outwards : They are ufually forced di- 
rectly forward, or in fome degree to the 
right or left lide. On this account it is 
extremely difficult to accomplifh their 
reduction, as the contents of the thorax 
or abdomen muft always ly between the 

injured 



Sect. VI. Spine, Qs Sacrum, &c. 199 

injured parts and the means ufed for this 
pur.pofe. 

Various means have been propofed, 
and different machines invented, for the 
reduction of diflocated vertebras. Thefe 
machines, however, mould be laid afide, 
as being not only ufelefs but dangerous ; 
for whoever has paid attention to the 
anatomy of the fpine, will fee, that in 
diflocations of the vertebra? fcarcely any 
advantage is to be gained from the ap- 
plication of much force, while a great 
deal of mifchief may evidently enfue 
from it. 

When one or more of the vertebrae 
are luxated forward, of which we can 
only judge by an accurate examination 
with the fingers, the moft certain me- 
thod perhaps of reducing the difplaced 
bones is, to bend the body flowly and 
gradually forward, as far as it can be 
done, over a cafk or any other cylindri- 
cal fubftance of a fuflicient fize. If the 
bone by this pofition regains its lituation, 
the body mould be immediately iraifed ; 

and 



loo Of Luxations of the Ch. XL, 

and the attempt lhould be repeated when 
it does not fucceed at firit. 

When the difplaced bone is ' pufhed 
much out of its natural fituation, neither 
this nor any other method will probably 
iucceed ; but it has certainly done fo in 
different inftances of partial diflocations; 
In bending- the body forward, the two 
vertebras lying contiguous to the one 
that is puihed forward are fomewhat far- 
ther feparated from each other ; by which 
the difplaced bone may, either by the 
compremon produced upon the abdomen, 
or by the ordinary action of the conti- 
guous mufcles, be forced into the fitua- 
tion it formerly occupied. 

When the diilocated bone, inftead of 
being puihed flraight forward, is forced 
in any degree to one fide, the body, while 
the reduction of it is attempting, fhould 
not only be bent forward, but fomewhat 
towards the affected fide; by which 
means the two contiguous vertebras will 
be feparated to a greater diftance than 

they 



Sect. VI. Spine % Os Sacrurh t <&c. 20 i 

they poflibly could be by bending it ei- 
ther directly forward or towards the op- 
posite fide. 

When any part of the os facrum is 
luxated, all we can do is to replace it 
with as much exactnefs as poflible by ex- 
ternal preffure, and by bending the bo- 
dy forward in the manner we have men- 
tioned. 

The coccyx is more frequently luxa- 
ted than any of thefe bones, as it isf 
equally liable to the fame kinds of inju- 
ries, befides being more expofed to the 
effects of falls, &c. . 

This bone may be luxated either out- 
wardly or inwardly. It is apt to be for- 
ced outwards in laborious births, when 
much violence is ufed in pulling down 
the head of a child. And in fome in- 
ftances the fame accident has occurred! 
from large collections of hard feces in 
the rectum. We judge of this injury 
having occurred, from the pain which 
takes plaqe all over the region of the 
loins, particularly about the junction of 

Vol. VI. o %L$ 



202 Of Luxations oftb? . Ch. XL^. 

the os coccyx with the facrum ; and 
from the, difplaced bone being difcover- 
ed upon examination with the fingers. 

When the coccyx is* luxated inwardly 
either by falls or blows, the patient com- 
plains of much pain, and a fenfation of 
a tumor or fome other hard body com- 
prefling the under t part of the rectum ; 
he is liable to tenefmus ; he finds much 
difficulty in pafltng the feces - r and in 
fbme inflances a fuppreffion of urine 
takes place. On the finger being intro- 
duced at the anus, the difplaced portion 
of bone is readily difcpvered. 

In outward luxations of the coccyx 
we feldom find much difficulty in re-; 
placing the bone by external preiTure 
with the fingers ; but it is often difficult 
to retain it in its fituation. It can only 
be done by fupporting the parts with 
proper comprefles and bandages. The 
T bandage anfwers for this purpofe bet- 
ter than any other. 

In the reduction of an internal diflo- 
cation' of this bone^ the fore-finger of 

one 



Sett. VI. Spine , Os Sacrum , &c. 203 

one hand, after being immerfed in oil,- 
fhould be paffed as far as poflible up the 
rectum. By means of it the bone mould 
be prefTed into its fituation j while with 
the other hand we fupport the parts which 
correfpond with it externally. "' 

As diflocations of thefe bones, particu- 
larly of the coccyx, are very apt to ex- 
cite inflammation, and as this is apt to 
terminate* in abfcefTes which do not rea- 
dily heal, we fhould omit nothing that 
may probably tend to prevent it. Blood- 
letting fhould be prefcribed in propor- 
tion to the ftrength .of the patient, par- 
ticularly local blood-letting by means of 
leeches, or cupping and fcarifying ; a 
lax ftate of the bowels fhould be prefer- 
ved ; and the patient fhould be confined 
to that pofture in which he is eafiefl:,. 
and to a low regimen. 



O 2 S E'C= 



2 - o4 Of Luxations Ch. XL- 



SECTION VIL 



Of Luxations of the Clavicles. 



TH E clavicles are joined externally m 
the fcapula at the acromion, and 
their interior ends are lupported by the 
upper part of the fternum* 

As the clavicles • are not pofleiTed of 
much ftrength, and being tied at their 
articulations to the contiguous bones by 
ligaments, they are more expofed to frac- 
tures than to luxations. In fome cafes, 
however, they are luxated. This may 
happen at either extremity of thefe bones, 
but it is more frequent at their junction 
with the fternum than at the acromion: 
for the force by which luxations of the 
clavicjes are produced, is for the moft part 
applied to the fhoulders, by which their 

oppo* 



Sect. VII. of the Clevises. 205 

oppofke ends are molt apt to be pufhed 
out. 

As the clavicles are thinly covered, 
luxations of either of their extremities 
are eafily difcovered : They are common- 
ly attended with a confiderable degree 
of ftiffnefs and immobility in the corres- 
ponding joint of the fhoulder ; for the 
neck of the fcapula having loft its fup- 
port, it is apt to.be dra^Hn out of its fitua- 
tion ; by which the motion of every mus- 
cle connected with the joint neceflarily 
becomes affected. 

A diflocation of the clavicle is eaiily 
reduced by moderate preffure with the 
fingers, efpecially if the arms and fhoul- 
ders be at the fame time drawn back ; 
by which the fpace which the clavicle 
fhould occupy may be fomewhat length- 
ened. It is more difficult, however, to 
retain the bone in its fituation, as it is 
apt to be again difplaced on the preffure 
being removed, by the ordinary action 
of the flexor mufcles of the arm. 

We derive little advantage here from 
O 3 fup~ 



206 Of Luxations Ch. XL. 

fupporting the arm. On the contrary, 
when the end of the clavicle connected 
with the fternum is difplaced, railing the 
arm does harm, as it tends to pufh the 
bone farther out of its place. It is, 
therefore, highly neceflary to attend to 
this diftinction in the management of 
fractures and luxations of this bone. In 
the latter, the raifed pofhure of the arm 
does mifchief : *n the ^former, it is of 
fervice, as we have fhewn in Chapter 
XXXIX. Sedion VII. 

It is neceflary, however, that the 
weight of the fore- arm mould be mode- 
rately fupported, to prevent the moul- 
der from being too much drawn dovfn. 
Eefides this, the head and moulders ought 
to be fupported, and a moderate prefliire 
made upon the difplaced end of the bone, 
Various bandages have been propofed 
for this, particularly the long roller ap- 
plied in fuch a manner as to form the 
figure of 8 upon the moulders and up- 
per part of the breaft. No advantage, 
however, is gained from any bandage of 



Se<5l. VII. of the Clavicles. 207 

this kind, as it cannot be retained fo 
firmly in its fituation as to produce any 
effect without impeding refpiration. The 
machine reprefented in Plate LXXXVIII. 
fig. 1. nearly the fame as is commonly 
ufed for fupporting the head, anfvvers the 
purpofe better than any other : for while 
it necelTarily raifes the head and keeps 
back the moulders, the (traps which pais 
over the upper part of the breaft may 
be made to act with fome force upon the 
diflocated end of the bone. It is fcarce- 
ly nccelTary to obferve, that the uie of 
this machine mould be continued for a 
confiderable time, otherwife the bone will 
be apt to ftaVt, when the whole will be to 
4.0 over again. 



O4 SEC- 



eo8 Of Luxations Ch. XL. 



SECTION VIII. 
Of Luxations of the Ribs, 



T has been generally fuppofed that the 
ribs cannot be diflocated ; and accor- 
dingly this variety of luxation has paf- 
fed -unnoticed by different writers on 
this branch of furgery. It is only at the 
articulation of the ribs with the verte- 
bra that luxations can happen ; and as 
they are connected with thefe bones by 
very ftrong ligaments, it is ufually ima- 
gined that they will break before they 
yield at the joints. 

It will readify appear, however, by an 
accurate examination of the junction of 
f.he ribs with the vertebra?, that they 
may be diflocated inwards. They can r 
not indeed be pufhed either upwards, 

down- 



Sea. VIII. of the Ribs. 209 

downwards, or backwards ; but we know 
from experience, that a ftrong force ap- 
plied near to their articulations will rup- 
ture their connecting ligaments, and 
thus pulh them forward. The ' fact has 
been proved by difTection after death. 

The fymptoms induced by diflocations 
will be nearly the fame with thofe which 
enfue from fractures of the ribs, viz. 
pain in the part affected, with difficult 
refpiration ; and if the end of the .bone 
be pufhed into the fubftance of the lungs, 
emphyfematous fwellings may enfue from 
• it. A diflocation, however, may be di- 
flinguifhed from a fracture, by the pain 
being moft fevere at the articulation, 
and by no part of the bone yielding to 
preflure excepting at this very fpot. 

I believe it will commonly happen, 
that the end of a luxated rib, in confe- 
quence of its elafticity, will return to its 
natural fituation when the caufe which 
produced the luxation is removed ; but 
when it does not, the beft method of re^ 
v ducing it will be to bend the body for- 
ward 



• 



2 1 o Of Luxations Ch. XL. 

-ward over a cafk or other cylindrical 
body, while the vertebras immediately 
above and below the rib are prefled in- 
ward with as much force as can with 
fafety be applied to them. After this, a 
thick comprefs of linen fhould be laid 
over the vertebrae we have mentioned, 
and another long one along the mod pro- 
minent part of the diflocated rib and the 
two immediately contiguous $ when, by 
means of a long broad roller pafTed two 
or three times round the body, fuch a 
degree of prefhire may be made upon 
the vertebrae as will retain them in their ° 
fituation ; while the prefTure made upon 
the projecting part of the rib tends to 
keep the end of it as fteadily as poflible 
in its fituation till the ligaments that 
were ruptured be again united. 

No bandage ufed for this purpofe 
fhould be applied with fuch tightnefs as 
to give any impediment to the breathing. 
The beft method of preventing the rol- 
ler from moving, is by the fcapulary 
fcandage pafTed over the fhoulders, and 



Sed. VIII. of the Ribs. 2 1 1 

a ftrap connected with it behind carried 
between the thighs and fixed to it be- 
fore. 

No diflecation whatever is more apt 
to induce inflammation of the contigu- 
ous parts, and other difagreeable fymp- 
toms. For the prevention and removal 
of thefe, nothing proves fo effectual as 
copious blood-letting, preferring the pa- 
tient cool and at perfect reft, a low diet, 
and opiates if a cough enfues and be- 
comes troublefome. o 



SECTION IX. 



Of Di/Iocations of the Humerus at the Joint of 
the Shoulder. 



TH E joint of the moulder is formed 
by what is ufually termed a Ball 
and Socket, the round head of the os hu- 
meri 



a 1 2 Of Diflocations of the Ch. XL. 

meri being lodged in a fuperficial cavity 
on the anterior part of the 'fcapula. 
This cavity is fo fuperficial, that in the 
Ikeleton it does not appear to contain a- 
bove a tenth part of the head of the hu- 
merus ; but in the recent fubject it is 
much more considerable, by means of a 
cartilaginous brim, the capfular liga*- 
ment, whi«h furrounds the whole joint. 
By this mechanifm, the moulder enjoys 
more free motion than other joints : but 
it is &t the fame time expofed to more 
frequent luxations ; infomuch, that there 
are more diflocations of the Ihoulder 
than of all the other joints of the bo- 
dy. 

The os humeri is moft frequently lux- 
ated downwards directly into the axilla, 
owing to the head of the bone meeting 
with lefs refiftance in falling into this 
iituation than in following any other 
direction. The head of the bone is 
jfometimes pufhed downwards and for- 
ward, and lodged beneath the pectoral 
mufcle, when we find it refting on the 

ribs 



Seel. IX. Joint of the Shoulder. 215 

ribs between the coracoid procefs of the 
fcapula and the middle of the correfpond- 
ing clavicle. In a few inftances it is dis- 
located downwards and backwards : but 
it can never be lifxated upwards without 
being accompanied with a fracture of 
the acromion ; of the coracoid procefs ;. 
or perhaps of both. 

The head of the bone, as we have al- 
ready obferved, for the mod part takes 
that direction in which it meets with the 
leaft refinance ; but this alfo depends in 
fbme degree on other caufes^* particularly 
on the part of the joint which received 
the injury, and on the fituation of the 
humerus at the time. Thus, if a blow 
falls upon the upper part of the joint, 
while the arm is in a direct line with the 
body, any diflocation that takes place will 
be downwards; while the head of the 
bone will moll probably be forced down- 
ward and inward by any ftroke given to 
the outfide of the joint while the elbow 
is ftretched back, and vice verfa. 

We 



214 Of Dijlocations of the Ch.XL. 

We judge that the humerus is difpla- 
ced by the patient being unable to move 
the arm ; by fevere pain being excited 
on every attempt to prefs the arm near 
to the fide ; by the arm t>eing of a diffe- 
rent length from, the other ; from its be- 
ing longer or fhorter according as the 
head of the bone is lower or higher than its 
natural fituation in the acetabulum fca- 
pulse ; by the head of the bone being felt 
either in the arm-pit beneath the perio- 
ral mufcle, or backwards below the ridge 
of the fcapula ; and by a vacancy being 
difcovered beneath the acromion. • If 
the two moulders be examined together, 
which fhould always be done, the found 
one will be found round and prominent, 
while the fore-part of the other, if much 
tumefaction has not taken place, will ap- 
pear to be flat, or even fomewhat hol- 
low. 

In luxations of long duration, the 
whole arm is apt to become cedematous, 
and to be in fome degree deprived of fen- 
fibility, from the preflure produced upon 

the 



Setf. IX. Joint of the Shoulder. 215 

the nerves and lymphatic vefTels of the 
arm by the head of the bone. All the 
other appearances we have mentioned, 
are likewife fo obvioufly induced by the 
difplacement of the head of the humerus, 
that fcarcely any of them, require to be 
explained. The head of the bone being 
thrown out of its natural* fituation, muft 
necelTarily affect the action of every muf. 
cle of the joint : Some will be too much 
relaxed, while others are too much ftretch- 
ed out : The motion 'of the joint muft of 
courfe be confiderably impaired. It is 
obvious too, that much pain muft be ex- 
cited by the arm being prefTed down to 
the fide, as the head of the bone will not 
only be forcibly rubbed againft fome part 
of the fcapula, but the foft parts on which 
it refts muft be greatly comprefTed, at 
the fame time that fome of the contigu- 
ous mufcles will be ftretched to a degree 
which they cannot eafily bear. 

In a fimple diflocation of the humerus, 
our prognofis fhould in general be favour- 
able ; for in recent cafes we feldom fail 

in 



1 1 6 Of D't/locatiotts of the Ch.XL. 

in reducing the bone. It muft be allow- 
ed, however, that inftances fometimes oc- 
cur, in which the utmoft difficulty is 
experienced in effecting a reduction ; but 
this is feldom the cafe where the treat- 
ment has been properly conducted from 
the nrft. In diflocations, indeed, of long 
continuance, the moft expert practition- 
ers often fail ; for in fuch cafes, the head 
of the bone has* often formed a fock- 
et among the contiguous parts, from 
whence it cannot be diflodged without 
tearing afunder fome of the mufcles 
with which it is furrounded ; and when 
diflodged, our endeavours may De ren- 
dered abortive by the cavity where the 
bone mould bfe lodged being too much 
diminifhed for receiving it. In all cafes, 
therefore, of long duration, although it 
may be proper to make fome attempts to 
replace the diflocated bones, yet none 
that requires any great degree of force 
fhould be much perfiffced in, for there is 
always fome uncertainty of their fuc- 
ceeding, while they neceflarily produce 



Sect. IX. Joint of the Shoulder. 217 

a great deal of pain, at the fame time that 
they are apt to render the motion of the 
head of the bone in the artificial focket, 
which it generally forms for itfelf, more 
ftifTthan it was before. 

In general it is fuppofed, that the re- 
duction is more eafily effected when the 
head of the bone is in the axilla than 
when it is pufhed forward beneath the 
pectoral mufcle ; and that in this filia- 
tion it is more readily done than when 
it is lodged backward beneath the fpine 
of the fcapula. The latter I believe to 
be fo ; but I have not found in the treat- 
ment of the others that there is any dif- 
ference between them. 

In the reduction of a diflocated hume- 
rus, we are in general told, that it is to be 
done by extenfion, counter extenfion, and 
the fubfequent application 6f fuch a force 
as is fufficient to replace the bone. Thefe 
three indications, however, may all be 
comprehended' in one. If a fufficient 
degree of extenfion be applied for draw- 
ing the head of the bone on a line with the 

Vol. VI. P ace- 



axS Of Difocatlons of the Ch.XL* 

acetabulum, the furgeon will feldom have 
any thing farther to do ; for when brought 
to this iituation, the reduction will al- 
moft in every inftance be completed by 
the ordinary action of the mufcles. 

All we have to do by counter exten- 
sion, is to fix the body fteadily while the 
arm is extending, and to prevent the fca- 
pula from being drawn forward by the 
force necefTary for moving the arm ; for 
if this bone be not fixed, it in fome de- 
gree moves forward with' the humerus, 
by which the force employed for ex- 
tending the arm is much lefTened, at the 
fame time that the cavity in the fcapula 
in which the head of the ' bone is to be 
placed, is thus kept- in a flate of motion, 
by which the redu&ion cannot be fa 
readily effected. 

This being done, our powers of exten- 
sion are applied to the arm, till the head 
• of the bone be drawn on a line with the 
brim of the focket ; when, as we have 
obferved above, it will inftantaneoufly 
flip into its place by the action of the 

con- 



Sect. IX. yo'int of the Shoulder. < no 

contiguous mufcles ; fo that there is no 
neceffity for the application of any force 
for this purpofe. Much mifchief has 
often been done by force applied with 
this view, as we fhall prefently fee on 
confidering the different modes of redu- 
cing luxations of this joint ; for it is ob- 
vious, if the force ufed for railing the hu- 
merus be applied before the end of it be 
drawn pail the mod projecting point of 
the fcapula, that the two bones mufh be 
thus preffed together fo as to obftruct 
the reduction. 

Various modes have been propofed for 
the reduction of diflocated moulders, in- 
fomuch that we feldom meet with two 
practitioners who do it in the fame man- 
ner : But as one or other of thefe muft 
be preferable to the reft, and as it is of 
much importance to have this afcertain- 
ed, we mall offer a few obfervations upon 
each of them, and fhall more particularly 
defcribe the one which we think mould- 
be adopted. 

1. The humerus is often reduced by pref- 
P 2 fure 



220 Of Dijlocations of the Ch. XL, 

fure with the heel upon the head of the 
difplaced bone. The patient being pla- 
ced upon the floor, the furgeon alfo fit- 
ting upon the floor, puts the heel of one 
foot, that of the left foot when he is ope- 
rating , t upon the left fhoulder, and vice 
verfa upon the head of the bone ; and 
laying hold of the fore-arm with both 
hands, he extends the arm, at the fame 
time that he endeavours with his heel to 
pufh up the bone. 

When the head of the bone has fallen 
directly downward into the arm-pit, we 
are directed by fome to place a fmall 
tennis ball or any other round fiibftance 
between it and the heel ; by which the 
preflure may be continued with more cer- 
tainty into the bottom of the axilla than 
where the heel alone is employed. 

This method, however, is liable to 
three very important objections. By lay- 
ing hold of the fore-arm, the joint of 
the elbow is confiderably flretched, by 
which it may be much hurt, while a great 
part of the force is loft upon it which 

ought 



5ed. IX. Joint of the Shoulder. 2 2 I 

ought to have been applied entirely to the 
os humeri : By extending the fort-arm, 
feveral of the mufcles of the arm itfelf, 
as well as the biceps flexor cubiti, are 
put upon the ftretch ; by which the exten- 
sion is made with much more difficulty 
than when thefe mufcles are relaxed by 
the joint of the elbow being properly 
bent. And, laftly, whether the heel be 
employed by itfelf or with a ball, it is 
much more apt to do harm than good ; 
for if it be not applied with fuch nicety 
as to pufh the head of the bone directly 
towards the focket, it muft necefTari- 
ly force it againft the neck of the fca- 
pula, or fome others of the contiguous 
parts, and will thus tend in the molt 
effectual manner to counteract the exten- 
fion of the arm, 

Befides, in this manner, the arm muft 
in every inftance be pulled in a very ob- 
lique direction downwards by the rela- 
tive fituation of the furgeon and patient ; 
whereas it mould in fome cafes be raifed 
P 3 nearly, 



222 Of Dislocations of the Ch.XL. 

nearly, though not altogether, to a 
right angle with the body, and kept in 
that polition while the extenfion is ma- 
king. 

It may be alleged, indeed, that this 
method often fucceeds, and that it has 
long been employed by fome of our old- 
eft and moft experienced practitioners. 
This I admit : but I alfo know that it 
often fails, even with thofe who fpeak 
moft favourably of it ; and that other 
modes of treatment have in various in- 
ftances completed the reduction, where 
this had preyioufly proved unfuccefsful. 

2. Others attempt to reduce this diflo- 
cation, by endeavouring to force the head 
of the bone into the focket with a rolling- 
pin applied beneath it, while a fufficient 
force is employed for extending the arm, 
and for fixing the body in its fituation. 
With a view to prevent the pin from 
hurting the fkin, we are defired to cover 
it with flannel, and that part of it which 
pafles into the axilla is directed to be 
more thickly covered than the reft. 

But 



Sea. IX. Joint of the Shoulder. 225 

* But however this may in fome inftan- 
«es have fucceeded, it ought by no means 
to be received into practice. It is evi- 
dently liable to mod of the objections 
we have mentioned to the mode of ope- 
rating with the heel ; particularly to the 
rifk of forcing the head of the humerus 
in beneath the neck of the fcapula, and 
thus counteracting the force employed 
for extending the arm. It is obvious, too, 
even on the principle upon which it is 
recommended by thofe who practife it, 
that this, as well as the mode of operating 
with the heel, cannot be applicable where 
the head of the bone is lodged either 
backward, or forward beneath the pecto- 
ral mufcle : for the fole intention of both 
is to raife the head of the bone ; and yet 
by fome they are ufed indifcriminately, 
whether the bone be luxated downwards, 
backwards, or forward. 

3. The patient being properly placed, 

the body fixed by afuftants, and the arm 

extended in the manner we flia.Il after- 

P 4 wards 



224 Of Dijlocat'ions of the Gh. XL. 

wards direct, fome furgeons make ufe of 
a towel or girth for pulling the head of 
the bone into the focket. The ends of 
the girth being tied together, one end of 
the double is put over the arm, and car- 
ried near to the head of the humerus ; 
and the other being paffed over the neck 
of the operator, he forces up the end of 
the bone by raifing his neck ; and if this 
could be done with fufTicient exactnefs, 
juft when the head of the humerus has 
cleared the brim of the focket, no harm 
would arife fromfhis part of the opera- 
tion ; but if the force for elevating the 
bone be applied before a fufficient degree 
of extension is made for this purpofe, it 
muft evidently do mifchief, by locking 
the head of the humerus and neck of the 
fcapula together : fo that this is in fome 
meafure liable to the fame objections we 
have flated to the mode of operating 
with the heel and rolling-pin. 

Thefe were the means ufually employ- 
ed for reducing luxations of this joint ; 

. but 



Sed. IX. Joint of the Shoulder. 225 

but being frequently found to fail, others 
have at different times been propofed in 
order to increafe the powers of exten- 
fion. 

4. Of this nature is the Ambe of Hip* 
"pocrates, as it is termed : It is the one 
that was chiefly employed by ancient 
practitioners, and in fome parts of Europe 
it is ftill the only inflrument ufed for 
this purpofe : For this reafon I have given 
a delineation of it in Plate LXXVI. fig. 1. 
but I do not by any means advife it to 
be employed. The powers of which it is 
poffeffed are great, but they cannot be 
properly applied ; fo that they are perni- 
cious in proportion to their extent. It 
is liable in a tenfold degree to the ob- 
jection we have dated above to the three 
preceding modes of reducing this bone, 
that of prefhng the head of it againfl the 
neck of the fcapula ; by which one or 
other of them mufk frequently be broke, 
as mud readily occur to whoever exa- 
mines " this inflrument with attention ; 

for 



226 Of Di/locattons of the Ch. XL* 

for inftead of extending the arm before 
raifmg the end of it, the firft action of 
this inftrument is to raife the extremity 
of the bone, by which it muft frequently 
be fo firmly pufhed in beneath the neck 
of the fcapula, as to counteract with much 
effect the power that is afterwards ap- 
plied for extending it. 

5. The method of reducing this joint 
by means of a ladder has been long 
known, but we hope not often employed. 
The diflocated arm being hung over the 
upper ftep of the ladder, to which heicht 
the patient muft be previoufly railed, 
and bemg fecuied in this (ituation by 
aihftants, the feat on which he is placed 
is fuddenly drawn away ; by which the 
whole weight of the body falls upon the 
luxated joint, and by which we are told 
the bone may often 'be reduced when 
other means have failed. The top of a 
high door is fbmetimes u/ed for the fame 
purpofe. Whether the door or ladder 
jbe employed, that part upon which the 

arm 



6etf. IX. Joint of the Shoulder. 227 

arm is made to red mould be well cover- 
ed with feveral plies of foft cloth. 

6. The patient being laid upon the 
floor, the bone has in fome inftances 
been reduced by two or three ftout men 
ftanding upon a table and lifting him up 
by the luxated arm. 

7. Upon the fame principle, it has 
been propofed to raife the patient by the 
luxated arm with ropes running over pul- 
lies fixed in the ceiling of a high-roofed 
apartment. The jerk produced by the 
body being fuddenly raifed and let down, 
has in fome cafes fucceeded where other 
attempts to reduce the humerus had 
failed. 

This was firfl practifed, I believe, by 
the ingenious Mr White of Manchefler ; 
and I have known it fucceed in different 
cafes of old luxations ; But thefe me- 
thods are all liable to great objections. 
The force is too fuddenly applied ; by 
which more mifchief may be done to 
the furrounding foft parts than can be 
compenfated by the reduction of the 

bone. 



228 Of Diflocations of the Ch. XL. 

bone. We know that mufcles, blood- 
veffels, and ligaments, will ftretch to a 
confiderable degree, if the extending 
force be applied in a flow gradual man- 
ner : but we alfo know, that they very 
readily break when powerfully and fud- 
denly ftretched. Of this we have a re- 
markable inftance in the burfting of the 
capfular ligaments of joints, which I be- 
lieve to happen, as has been already re- 
marked, in almoft every cafe of luxation 
from external violence. This leads us 
to fay, that any force that is ufed for 
the reduction of luxations fhould be ap- 
plied in the moft gradual manner, and 
that the mode of operating we are now 
confidering mufl frequently do mifchief 
by tearing and lacerating the foft parts 
furrounding the joint. Of this I have 
had various inftances even where the te- 
guments have been protected in the moft 
cautious manner, by covering them with 
fbft flannel, and afterwards with firm 
leather, before applying the ropes for 
extending the arm. 

Befides, 



Sect. IX. Joint of the Shoulder. Iig 

Befides, in thefe modes of reduction, 
the arm muft be always extended in the 
fame direction, whether the bone be lux- 
ated forward, downward, or backward : 
Whereas the direction in which the arm 
is extended fhould vary according to 
thefe circumftances ; as muft be obvious 
to whoever attends to the anatomy of 
the parts concerned in the luxation. 
Nay, in one variety of luxation, irrepa- 
rable mifchief may be done to the joint, 
by extending the arm in a direction 
which, in another variety of the injury, 
might not only be proper but necefTary. 
Where the head of the humerus is pufli- 
ed forward beneath the pectoral mufcle, 
or directly backward, we may readily 
fuppofe that it may be eafily reduced 
by pulling the arm upward, as is done 
when the body is fufpended by a pully 
in the manner we have mentioned ; 
while much harm may be done by it 
where the head of the bone is lodged 
in the axilla, and pufhed beneath the 
neck cf the fcapula. In this cafe, the 

end 



l$& Of Dtflocatlons of the Ch.XL- 

end of the humerus is often fo firmly 
wedged between the fcapula and ribs, that 
one or other of thefe bones would neceffa- 
rily break by the fudden application of 
much force in this direction ; and it can 
only be prevented by extending the arm 
fomewhat obliquely downward till the 
head of the humerus be quite difengaged. 
8. A machine has been invented for 
conjoining the power of the ambe with 
the mode of operating we have juft been 
confidering ; in which the patient's bo- 
dy is nearly fufpended by the diflocated 
arm, and is fuddenly raifed and let down 
again while the operator endeavours- 
with the lever of the ambe to elevate the 
head of the bone. The invention is in- 
genious, and the inttrument is evidently 
powerful ; but if our objections to thefe 
two modes of operating, taken feparatelv, 
are well founded, they are no lefs fo 
when they are combined. The powerful 
action of the lever mud be hazardous in 
proportion to the uncertainty of its ap- 
plication. While the body i s quickly 

rifing 



Sect. IX. Joint of the Shoulder. 231 

rifing and falling, the lever cannot pof- 
fibly be applied with exactnefs to the 
end of the bone ; and if it be made to 
act with much force before the head of 
the humerus is cleared of the fcapula, 
one or other of thefe muft neceflarily 
be fractured. 

9. When the more fimple methods of 
reducing luxations have failed, ropes 
and pullies have fometimes been employ- 
ed for diflodging the difplaced bones. 
Of thefe, different forms may be feen in 
Plate LXXVII. fig. 2. in Scultetus, Plate 
XXII. fig. 1 . and in Plate X. fig. 7. of De- 
fagulier's Experimental Philofophyl By 
means of one or other of thefe, any de- 
gree of force may be applied that can 
ever be required for this purpofe. 

10. But when recent cafes are proper- 
ly managed, luxations may in almoft 
every inftance be reduced without any 
afhftance from machinery. I have of- 
ten fucceeded by the moderate extenfion 
I was able to make of the arm with one 

hand, 



1$l Of Diflocaiions of the Ch.XL 3 

hand, while the other was employed iri 
preffmg back the fcapula. This, how- 
ever, requires all the mufcles of the arm 
and fore-arm to be as much relaxed as 
poflible ; which we accomplifh by bend- 
ing the elbow moderately, railing the 
arm to a height fomewhat lefs than a 
right angle with the body, and prefer-: 
ving it in fiich a direction as to prevent 
either the pectoral or extenfor mufcles 
of the arm from being flretched. When 
the arm is in this fituation, we often 
find luxations eafily reduced which had 
previoufly refilled the greateit force r 
for in this manner we not only relax the 
mufcles of the arm, but the capfular li- 
gament of the joint ; by which the head 
of the bone returns more readiJy by the 
opening at which it was forced out than 
it otherwife poflibly could do. ' For when 
the ligament is much ftretched, the neck 
of the bone will be firmly graiped by it, 
by which our being able to return ir 
will neceftarily be rendered mere uncer- 
tain. 

More 



Se&.IX. Joint of the Shoulder. 233 

More force, however, is fometimes re- 
quired than can be applied in this man- 
ner ; and the following is the method 
by which I have in every inftance of 
recent luxations fucCeeded. The patient 
is feated upon a chair, and his body fe- 
Cured by a long broad belt palled round 
itj and given to afliftants, or tied round a 
jpoft : a firm band of leather, four or five 
inches broad, and lined with flannel, as 
is reprefented in Plate LXXVII. fig. 3. is 
now to be tied round the arm immedi- 
ately above the elbow. The three ftraps 
or cords connected with this band being 
given to afliftants, they muft be delired 
to extend the arm in the relaxed pofition 
we have mentioned, and in a flow equal 
manner, while another afliftant {landing 
behind is employed in prefling the fca- 
pula backward. The furgeon himfelf 
ftands mbft covenicntly on the outride 
of the arm : His bufmefs is to direct the 
afliftants in the degree of force they are 
to employ, and to point out the direc- 
tion in which the arm is to be extended ; 

Vol. VI. Q^ he 



3-34 Of Diflocations of the Ch.XL* 

he may alfo- fupport the fore-arm and 
retain it bent at the elbow, in the man- 
ner we have mentioned. As foon as the 
head of the bone is drawn clearly paft 
the brim of the focket, the extenfion of 
the arm mould be fomewhat relaxed, 
when the reduction will for the moft 
part be accompliihed by the action of 
the mufcles of the joint ; or it will be 
readily effected by moving the arm 
gently in different directions. A crack 
is heard on the bone flipping in ; the pa- 
tient finds immediate relief; and the 
anterior part of the fhoulder acquires it* 
ufual prominent form. 

The direction in which the arm is ex- 
tended muft depend upon the fituatioa 
of the head of the bone : that in which 
it will meet with the leaft refiftance is 
always to be preferred. When the head 
of the bone is pufhed forward, and lodg- 
ed beneath the pectoral mufcle, the arm 
fhould be raifed to a right angle with 
the body, and the fame direction will 
stfiiwer where it is puihed backward : But 

in 



Sect. IX. Joint of tht Shoulder, 23-5 

in the moft frequent kind of luxation 
of this joint, where the head of the bone 
is lodged in the arm-pit, the arm mould 
uniformly be drawn lomewhat obliquely 
downward : If extended when raifed to 
a right angle with the body, it would be 
drawn againft the neck of the fcapula^ 
by which much pain would be excited, 
and the reduction fruftrated. Of this I 
have feen many inftanCes, as every prac- 
titioner muft have done. 

It fhould be a general rule in the 
treatment of every luxation to vary the 
direction in which the extenfion is made 
as foon as we meet with any confiderable 
refiftance ; but in luxations of the hu- 
merus, attention to the obfervations we 
have juft thrown out will for the moft 
part prove fufficient. 

In reducing luxations of this joint, it 
has been the prevailing practice to prefs 
the fcapula forward and downward ; 
Nearly the reverfe of this, however* 
fhould be adopted. By prefTing the fcapu- 
la downward we force it againft the head 
Q^2 of 



2 3^ Of Dijlocatlons of the Ch.XL> 

of the humerus, the very thing we ought 
mofl carefully to aviod : and by forcing 
it forward, it is evident that the end of 
the humerus will not be fo.eafily drawn 
out from beneath it as when the amftant 
is defired to pull it backward in the 
manner we have mentioned. 

1 1 . The mode of treatment I have juft 
been defcribing will fucceed in almoft 
every inftance of recent luxation ; and 
it will feldom fail even in cafes of long 
{landing, where reduction of the diflo- 
cated bone is practicable : But when a 
greater force is required than can be ap- 
plied in this manner, the inftniment re- 
prefented in Plate LXXVIII. may be em- 
ployed. It was invented by the late Mr 
Freke of London ; and it anfwers the 
purpofe of extenfion better, and with 
more exactnefs, than any other I have 
feen. It is delineated exactly from the 
plate given of it by Mr Freke ; but it 
admits of fome improvements. The 
flrap A A which paffes over the moulder 
prefTes down the fcapula, and thus im- 
pede* 



Sed. IX. Joint of the Shoulder. 1 37 

pedes the reduction of the bone: It 
mould therefore be either entirely want- 
ing, or made with a flit to pafs over the 
arm fo as to draw back the fcapula : in 
which cafe, inftead of pafling obliquely, 
downwards to be fixed in the floor, it 
ihould pafs ftraight acrofs, and be fixed in 
a pofl on a line with the fhoulder. 

We have already obferved that the ufe 
of a lever in railing a luxated humerus 
is both unnecefTary and dangerous : The 
lever of this inftrument, therefore, in- 
ftead of being moveable, mould be fixed 
fo as only to ferve as a fupport to the 
arm ; or if it ever be ufed as a lever, it 
mould be managed with the utmoft cau- 
tion. The principal advantage derived 
from this inftrument is our being able, 
by means of it, to apply any force that 
, may be necefTary in the molt gradual 
manner, an object of the flrft importance 
in the reduction of luxations : It alfo 
extends the arm in any direction we may 
judge proper ; by which it can at once 
Q^3 be 



238 Of D'ljlocatiom of the Ch. XL \ 

be adapted to any variety of fuch in- 
juries. 

Swelling, pain, and inflammation, when 
they occur as confequences of luxations 
of the arm, are to be removed by the re- 
medies ufually employed in fuch cafes, 
but chiefly by local blood-letting by 
means of leeches. 

The round head of the biceps flexor 
cubiti, which pafTes through the joint 
of the moulder, and is lodged in a groove 
in the head of the humerus, is apt to be 
feparated from this bone when it is for- 
ced far out of its natural fituation, and 
thus induces a (tiff unwieldy flate of the 
arm : for the moft part it returns im- 
mediately to this groove on the difloca- 
tion being reduced ; and we fufpedl that 
it continues to be difplaced when any 
unufual pain, fcifFnefs, or tenfion remain. 
The moft certain method of replacing it 
js to move the arm from time to time in 
every variety of way ; and we know that 
it is replaced, by an inftantaneaus remo- 
val of the diftrefs. 

The glenoid cavity of the fcapula be- 
ing 



Setf:. IX. Joint of the Shoulder. 239 

mg very fuperficial, the head of the hu- 
merus is apt to fall out again, even after 
it has been completely replaced ; parti- 
cularly when it has been frequently lux- 
ated. The mod certain method of pre- 
venting this is to fupport the arm in a 
fling, as is reprefented in Plate LXXXI. 
fig. 2. till the parts recover their tone. 
Blifters applied to the moulder, and 
pumping cold water over the joint, have 
alfo proved ufeful for this purpofe. 



SECTION X. 



[ Of Luxations of the Fore-arm "at the Joint 
of the Elbow. 



THE bones of the fore-arm at the el- 
bow are more frequently diflocated 
upward and backward than in any other 
direction : They can fcarcely be luxated 
laterally or forward, if the injury be not 
Qjf at 



240 Of Luxations of the. Ch. XL, 

at the fame time accompanied with a 
fracture of the olecranon or top of the 
•ulna, as will be readily perceived on ex- 
amining the connection of that proceft 
with the cavity in the pofterior part of 
die os humeri. 

As the joint of the elbow is not deep- 
ly covered with foft parts, any luxation 
of the bones is eafily difcovered as long 
as fwelling and tenuon have not taken 
place. When thefe fymptoms occur to 
any extent, it is often difficult to diftin- 
guiih either the nature or extent of the 
injury with which they are connected. 
When the luxation is backward, the ole- 
cranon is felt on the back part of the 
arm, and the condyles of the humerus 
are pufhed forward. When the olecra- 
non is broke, and the ulna and radius 
puihed forward, they are alfo apt to be 
drawn upward on the anterior part of 
the humerus, when the condyles of that 
bone are difcovered behind. The ex- 
pent of the joint is fo confiderable from 
one fide to the other, that the bones 

com- 



Se&.X. Fore-arm at the Elbow. t+l 

compofing it can never be completely 
luxated laterally, unlefs the foft parts 
with which they are covered are much 
lacerated. In whatever way they arc 
dii placed, the joint becomes immediate- 
ly ftiff and immoveable. 

In the reduction of thefe diflocations 
the patient mould be feated on a chair 
of a convenient height, and the arm 
firmly fecured by an affiflant : where 
the bones are luxated backward, the 
fore-arm fhould be moderately bent, in 
order to relax the flexor mufcles : while 
in this polition it fhould be flowly and 
gradually extended ; and if care be ta- 
ken to increafe the curvature of the el- 
bow in proportion as the extenfion is 
made, we will feldom or never fail in 
completing the reduction. Where the 
olecranon is broke, and the ends of the 
radius and ulna pufhed forward and 
drawn up upon the humerus, we are 
under the neceflity of extending the arm 
while in a ftraight pofition, as in this 
cafe the heads of thefe bones are pufhed 

back 



h^z Of Luxations of the Ch. XL. 

back upon the anterior part of the hu- 
merus on the leaft attempt to bend 
them. The extension ihould be continu- 
ed till the ends of both bones are pulled 
fomewhat lower than the mod depending 
point of the humerus, when "they will 
cither regain their fituation by the ac- 
tion of the mufcles, or be eafily forced 
into it. 

In lateral diflocations of thefe bones 
the extenfion rauft alfo be continued till 
they have clearly paffed the end of the 
humerus, when by moderate lateral pre£ 
fure they will for the moft part be 
eafily replaced. Of whatever kind the 
diflocation may be, the extenfion fhould 
be made by affiftants grafping the arm 
immediately above the wrift ; and while 
they are thus employed, much advantage 
may be gained by the furgeon prefhng 
down the heads of the bones. 

In two cafes of diflocation of thefe 
bones, where their heads were drawn up 
Upon the back of the humerus, the re- 
duction was not accomplifhed, although 

a 



8e<5t. X. Fore-Arm at the Elbow. 243 

a great force was applied, not only in 
pulling at the under part of the arm, but 
in pufhing down the heads of the dis- 
placed bones. In one of them, where the 
olecranon was pufhed through the tegu- 
ments, that part of the bone was fawn 
off, by which the reduction was effected : 
In the other, this expedient was not ad- 
vifed ; and the practitioner finding all his 
efforts to reduce the bones prove abortive, 
the limb was amputated. As the exten- 
fion in both was applied while the arm 
was ftretched out, and as I have never 
failed in fimilar cafes where the arm was 
bent, I conclude, that in the one the arm 
would have been faved, and in the other 
the joint preferved entire, if this practice 
had been adopted. 

The -reduction being completed, the 
fore-arm mould be kept in that pofition 
which tends mod effectually to relax all 
the mufcles connected with it. The el- 
bow being moderately bent, anfwers this 
purpofe in the mofl certain manner. 

Thefe bones, when reduced, do not 

readily 



244 Of Luxations of the Ch. XL* 

readily fall out again ; but it is proper 
in this, as in every cafe of luxation, to 
preferve the limb as much at reft as pof- 
fible till the injured parts have recover- 
ed their tone. 

The bones of the fore- arm are alfo 
liable to be diflocated in their connection 
with each other. At the joint of the 
elbow a projecting part of the radius is 
lodged, and moves in a correfponding 
cavity of the ulna j and below, a portion 
of the ulna is received by a fimilar ca- 
vity in the radius. Inftances have oc- 
curred of thefe bones being feparated 
from each other at both thefe points of 
connection j but any feparation of this 
lend is more apt to happen at the wrift 
than at the elbow. It is known to have 
occurred, by all the ufual figns of luxa- 
tions : By pain, fwelling, and diftortion 
in the injured part; by the motion of 
the joint being impaired ; and by ma<- 
nual examination. 

In general the diiplaced bone is eafily 
put into its iituation } but for the mod 

fm 



Sedl. X. Fore-arm at the Elbow. 245 

part we find it difficult to retain it. The 
rrioft certain method of effecting this is, 
to put a long firm fplint along the out- 
fide of the arm ffom the elbow down to 
the points of the fingers, and another of 
the fame length on the infide ; the whole 
to be fecured with a flannel roller, and 
the arm hung in the fling reprefented in 
Plate LXXXI. fig. 2. By this the rotatory 
motion performed by the radius, and the 
pronation and fupination of the hand, is 
prevented ; and if this is guarded againfl 
for a fufficient length of time, a cure 
may at laft be expected : While want of 
attention to this point is frequently the 
caufe of the joint at the wrift remaining 
ftifF for life ; of which I have met with 
various inftances. 



SEC- 



&q.() Of Luxations of the Ch.XL'i 



SECTION XL 

Of Luxations of the "Bones of the Wrift. 

THE bones of the wrift are not fo fre- 
quently luxated as might be ex- 
pected from the finallnefs of their fize, 
owing to their being firmly connected 
by ligaments, as well as to the flrength 
which they derive from the whole tend- 
ing to form a kind of arch ; the convex 
part of which being on the outer or 
back part of the hand, where it is moft 
expofed to injuries, is particularly well 
calculated for preventing any of the bones 
from being dilplaced. 

Degrees of force, however, are fome- 
times applied to them which they are 
unable to refift. From their form, it 
will appear that they will moil: readilv 
be diflocated outward. The three fupe- 
rior carpal bones that form a kind of 

pro- 



Secl.XI. Hones of the Wrifi. £47 

projecting head, that is lodged in a fu- 
perficial cavity in the under extremities 
of the ulna and radius, may either be 
diflocated at this joint, or they may be 
feparated from the five inferior bones of 
the wrift. In fome inflances one or 
more of thefe bones are feparated from 
each other ; and in others they are diflo- 
cated at their connection with the bones 
of the metacarpus and the fuperior bone 
of the thumb. 

As thefe bones are not thickly covered 
with foft parts, the nature of the injury 
becomes immediately obvious when they 
are completely luxated : But in fome 
eafes, where perhaps a {ingle bone is only 
partially difplaced, if the parts be not 
examined with attention, the fymptoms 
which occur are apt to be attributed to 
a fprain ; and the real caufe of them be- 
ing overlooked, a permanent lamenefs is 
thus induced, which with much eafe 
might have been prevented. Of this I 
have met with various inflances. Simi- 
lar occurrences, however, may always 

be 



*4& Of Luxations, -fcfc. Ch.XL, 

be prevented by an early arid attentive 
examination of the injured parts. 

In reducing luxations of thefe bones, 
we are in general defired to ftretch the 
arm and hand upon a table, and while 
they are in this polition to pufh them in- 
to their fituations : But it is better to 
have the arm and hand fupported by two' 
amftants, as in this fituation the furgeon 
gets ready accefs to each fide of the 
wrift. The affiftants fhould be defired 
to keep the parts fufficiently firm, but 
not to ftretch them ; and when in this fi- 
tuation, the furgeon will feldom find 
it difficult to pufh the bones into their 
places. They muft be retained by fplints 
and bandages in the manner mentioned 
in the laft fection ; and as diflocations 
of thefe bones are very apt to induce 
inflammation of the ligaments and other 
contiguous foft parts, repeated applica- 
tions of leeches fhould be advifed as the 
moft certain preventative. 



s£c« 



vig. i. 





Sect. XII. Of Luxations^ 6*. 24$ 



SECTION XII. 



Of Luxations of the Bones of the Metacarpus $ 
and Finger Si 

WE have feen in the laft fection that 
the metacarpal bones may be dife 
located at their junction with the bones 
of the wrift ; and they are fometimes dis- 
placed at their under extremities, where 
they are connected with the bones of the 
fingers. They are not fo frequently lux- 
ated, however, as at firft view might be 
expected ; probably from the joint of the' 
Wrift being fo moveable, that the whole 
hand readily yields to any force that is 
applied to it; 

The bones of the fingers and thumb 
are alfo*fometimes luxated ; but we like- 
wife confider the mobility of thefe bones 
as the principal reafon of their being lefs* 
frequently diflocated than many of the' 

Vol. VI. R largefifc 



2 5° Of Luxations of the Ch. XL, 

largeft and ftrongeft bones that are much 
more firmly connected together. 

Diflocations of thefe bones are eafily 
difcovered by the ufual fymptoms which 
take place in luxations ; but particularly 
by the deformity which they produce,, 
which in this fituation is always confpi- 
cuous. 

When any of the metacarpal bones 
are difplaced at their connection with 
the bones of the wrift, the be ft method 
of reducing them is, by keeping the arm 
fteadily fixed, and pufhing them from a- 
bove downward, while the hand remains 
loofe and moveable. When the firft pha- 
lanx of any of the fingers is moved from 
its junction with the corresponding me- 
tacarpal bone, it is to be replaced by one 
affiftant fixing the hand, while another 
■draws down the diflocated finger, which 
fhould be done by grafping the firft pha- 
lanx on]y, in order to prevent the other 
joints of the finger from being hurt. 
Diflocations of all the other joints of the 

fingers. 



SetSl. XII- Metacarpus and Fingers. 251 

fingers, as well as of the thumbs, are to 
be managed in the fame manner. 

In the reduction of thefe diflocations, 
the bone mould not be pulled down till 
it be fomewhat raifed or elevated from 
the contiguous bone ; for as all the bones 
of the fingers and thumbs, as well as 
thofe of the metacarpus, are confiderably 
thicker at their extremities than in any- 
other part, thefe projections are apt to 
be forced againft each other when the 
extenfion is made in a ftraight direction. 
In this manner the greateft force has 
frequently been employed in vain ; nay, 
fingers have been amputated where this 
caufe alone prevented luxations from be- 
ing reduced, and in which a very incon- 
fiderable force would have proved fuc- 
cefsful, if the difplaced bone had been 
fomewhat feparated from the other be- 
fore any force was applied for extending 
it. 



R 2 S EC 



'^5 2 Of Luxations of tht Femur Ch. 2CL. 

SECTION XIII. 
Of Luxations of the 'Femur at the Hip- Joint. 



HTHE focket or acetabulum formed by 
the ofla innominata for lodging the 
head of the thigh-bone is fo deep ; the 
brim of the focket in a recent fubjedt 
contracts fo much as even to grafp the 
neck of this bone ; the head of the bone 
is fo firmly tied down to the bottom 
of the focket by a ftrong ligament ; and 
it is fo confined by ftrong mufcles, that 
■we would not a priori fuppofe that it 
could be luxated by external violence: 
We would rather imagine that it would 
break at the neck where it is weakeft, 
than that the head of it mould ever be 
forced from its focket : This opinion has 
accordingly been adopted by many in all 
ages. For a considerable time I was dif- 
pofed to favour it, from having obferved 

feveral 



Sea. XIII. at the Hip-Joint. 253. 

feveral cafes which at firft were fuppofed 
to be luxations, but which proved co be 
fractures of the neck of the femur. In 
the courfe of the laft few years, however, 
I have feen feveral cafes in which I was 
convinced that the thigh-bone was luxa- 
ted. The nature of the fymptoms gave 
reafon to imagine that they arofe from 
luxations ; and they were proved to do fo 
by the patient's being inftantaneoufly and 
completely relieved, on the head of the 
bone being replaced. 

In treating of fractures of the thigh- 
bone, we mentioned the circumftances 
by which fractures of the neck of it may 
mofl readily be diftinguifhed from luxa- 
tions : We rauft therefore refer for this 
part of our fubject to the eleventh Section 
of the preceding Chapter. 

It is faid by authors, that the head of 
the femur may be luxated in various di- 
rections, namely, upward and backward, 
upward and forward, downward and 
backward, downward and forward, and 
I may add directly downward. That all 
R 3 of 



2 54 Of Luxations of the Femur Ch. XL, 

of thefe may happen, I cannot take upon 
me to deny ; but I believe few practition- 
ers have met with an inflance of the firft 
and third. The fecond variety, where 
the head of the bone paffes up upon the 
os pubis, may happen ; as may likewife 
the laft, where it is forced directly down : 
but I have never feen any variety except 
that in which the head of the femur is 
pufhed downward and forward, and lodg- 
ed in the foramen ovale. All practi- 
tioners admit, that the bone is moft fre- 
quently diflocated in this direction ; and 
an examination of the fkeleton, as well 
as of the recent fubject, will mow why 
it fhould be fo. The brim of the focket 
over all the upper and back part of it, 
is not only ftronger, but more elevated 1 
than in the reft of it. It falls away as 
it defcends ; and on the anterior under 
part of it there is a confiderable vacancy 
in the bone", the fpace being filled with 
a ligament only : and as this opening is 
iufhciently large to admit the head of 

the 



Sea. XIII. at the Hip-Joint, 255 

the femur, we are led to imagine that 
luxations will be mod apt to occur here. 

Every luxation of the femur mud be 
productive of lamenefs, and of pain, ten- 
sion, and other fymptoms with which 
luxations in general are accompanied. 
When the head of the bone paffes up- 
ward and backward, the leg will be con- 
siderably fhorter than the other ; info- 
much that the points of the toes will on- 
ly touch the ground when the patient is 
Handing upon the other foot ; the great 
trochanter of the thigh-bone will be 
much higher than in the other fide ; the 
knee and foot will be turned inward ; and 
a good deal of pain will be induced by 
every attempt to turn them out. 

When the femur is luxated upward 
and forward, the leg will be fhortened ; 
the head of the bone will be felt retting 
upon the os pubis in the groin; the 
great trochanter will be on the upper and 
anterior part of the thigh near the groin, 
while a vacancy will be difcovered in 
that part of the hip which it ought to 
R 4 occupy ; 



$5^ . Of Luxations of the Femur Ch. XL. 

occupy ; the knee and toes will be turned 
outwards ; and if the diflocation be not 
foon reduced, pain, tenfion, and inflam- 
mation, will probably occur in the fperr 
made cord and teftis, from the preflure 
made upon the cord by the head of the 
bone. 

If ever this bone be luxated down- 
ward and backward, the leg will be con- 
siderably longer than the other ; the 
knee and toes will be turned inward ; 
and the great trochanter will be much 
lower than the fame protuberance of the 
other limb. When the head of the bone 
paries directly downward, the leg will 
alfo be longer than the other, and the 
trochanter will likewife be lower ; but 
the knee and toes will retain nearly their 
natural fituation ; only, every attempt to 
move them will be productive of pain. 

In the moft frequent luxation of the 
femur, the leg appears to be considerably 
longer than the other ; the knee and 
points of the toes are turned outward, 
nor can they be moved either farther 

outward 



Sea. XIII. at the Hip- Joint. i$-j 

outward or inward but with much pain ; 
all the mufcles in the internal part of 
the thigh are tenfe and painful ; the fe- 
mur cannot be felt on the outfide far- 
ther up than the middle of the thigh ; 
a vacancy is difcovered in the ufual feat 
of the great trochanter, which is found 
farther down and on the anterior part 
of the thigh, while the head of the fe- 
mur is plainly felt a little below the 
groin, being feated, as we have obferved 
above, in the foramen ovale. 

In all luxations of the femur, the diffi- 
culty and uncertainty of reducing them 
has been confidered as fo great, that in ge- 
neral we have been advifed to give a very 
doubtful prognofis of the event. In cafes 
of long duration this Ihould always be 
done : for befides other caufes which 
add to the difficulty of reduction, the 
mufcles here are fo ftrong that they re- 
fill, in the moft powerful manner, every 
attempt to diflodge the head of the bone 
after it has been long fixed among them ; 

by 



2 5 8 Of Luxations of the Femur Ch.XL, 

by contracting round the neck of the 
bone, they muft even be tore afunder 
before it can be reduced : But in recent 
luxations we have |not this difficulty to 
encounter ; and we' know that with pro- 
per management the bone may in almoft 
every infhance be reduced. 

The reduction of this bone is always 
attempted by pulling the limb down- 
ward ; and it feems to be an opinion very 
univerfally received, that any force we 
employ fhould be applied in this direc- 
tion. Some advife the limb to be drawn 
directly down from the part in which 
the head of the bone is lodged ; others 
defire it to be pulled exactly in a line 
with the hip-joint, while others turn the 
knee fomewhat inward. The patient 
being placed upon his back and properly 
fecured, the limb is extended in one or 
other of thefe directions, either till the 
reduction is accomplifhed, or till fuch a 
force is applied as makes the operator 
afraid of doing harm were he to proceed 
farther. 

It 



Sea.XIII. at the Hip-Joint. 259 

It mud be allowed that dillocations of 
the femur have in various inftances been 
reduced in this manner : it might often 
fucceed where the head of the bone is 
forced upwards ; but I may without hefi- 
tation afTert, that even in this cafe the 
reduction might be effected with lefs 
force in a different manner ; and in a 
great proportion of cafes where the head 
of the bone is lodged in the foramen 
ovale, or where it is forced directly 
downwards, that we muft neceffarily 
fail entirely by confining the line of ex- 
tenfion to any of the directions we have 
mentioned. 

In whatever way the head of the fe- 
mur is luxated, it muff pafs over fome 
inequalities or prominent parts of the 
contiguous bones : Thefe it muft again 
pafs over before it be reduced ; at lean: 
this muft be the cafe if we wim it to re- 
turn by the fame route : And it will be 
admitted in the treatment of luxations 
to be a good general rule, to endeavour 
to replace the bone by the opening at 

which 



260 Of Luxations of the Femur Ch.XL. 

■which it paffed out. But where the limb 
is only pulled downward in the ufual 
way, the head of the bone will be forced 
againft the projecting brim of the focket, 
if the oTiflocation is upward ; or it will 
be drawn to a ftill greater diftance from 
the joint where the bone is diflocated 
either directly downward, or lodged in 
the foramen ovale in the upper and in- 
ner part of the thigh. Wherever the 
head of the bone may be lodged, it 
mould be completely raifed above any 
projecting part of the contiguous bones 
before any other attempt is made for re- 
ducing it. As this will remove the prin- 
cipal impediment to the reduction, if 
the mufcles of the limb be at the fame 
time relaxed, it will eafily be drawn into 
the focket when the diilocation is up- 
ward, or puihed into it where the head 
of the bone is already beneath it. 

In the mofl frequent variety of this 

.luxation, where the head of the bone is 

pufhed downward and forward, I have 

iiicceeded in the following manner : 

The 



I LAJ.TV L.\.\.\ 



c 


c B 




• H 


r 





riG-. t. 





Sea. XIII. at the Hip- Joint. 261 

The patient is laid upon his back acrofs 
a bed, and firmly fecured by an afTiftant 
or two : A broad (trap, or table-cloth 
properly folded, is pafTed between his 
thighs and over the groin on the found 
fide, and given to two other amftants : 
A fimilar (trap is paffed round the lux- 
ated thigh as near as poffible to the head 
of it ; the ends of which muft be given 
to an afTiftant (landing on the oppo- 
fite fide : The belt reprefented in Plate 
LXXVII. fig. 3. being previoufly fixed 
upon the under part of the thigh, the 
ftraps connected with it are given to an 
afTiftant or two, while the knee is fup- 
ported by another afTiftant with the leg 
moderately bent. The thigh is now to 
be moderately ftretched by the afliftants 
who have the charge of the ftraps at the 
under part of it; but the extenfion 
fhould not be carried farther than what 
may be confidered as neceffary for draw- 
ing the head of the bone down to the 
under part of the foramen ovale ; and 
this we may always effect: with a very 

mo- 



262 Of Luxations of the Femur Ch. XL; 

moderate force. The (trap round the 
root of the thigh mull now be firmly- 
pulled by thofe who have the charge of 
it ; who, fb.nding fomewhat higher than 
the patient, ihould draw the thigh up- 
ward and inward ; and the extenfion 
ihould be continued in this direction 
till there is reafon to fuppofe that the 
head of the bone is clearly raifed from 
the foramen in which it was lodged. At 
this time the perfon who has the charge 
of the knee mould be defired to move it 
fomewhat inward, and to pufh the thigh 
upward and obliquely outward : he will 
do this with the greateft certainty of 
fucceeding, if he fecures the knee with 
one hand and the foot with the other, 
at the fame time that he takes care to 
keep the leg juft fo much bent as may 
relax all the flexor mufcles without 
ftretching the extenfors. If the different 
affiftants perform their parts properly, 
"the flrrr. attempt will prove fuccefsful j 
but if any of them have failed, particu- 
larly if the head of the bone has not 

been 



Se&.XIII. at the Hip-Joint. 26$ 

been fufficiently raifed from the hollow 
in the foramen ovale before being pumed 
upwards, the attempt mud be repeated. 

As the head of the bone may for the moft 
part be felt outwardly, the furgeon may in 
general afcertain with certainty whether 
it be fufficiently raifed or not. If he 
finds it rife eafily, the force may be con- 
tinued till it appears to be about an inch 
higher than when it was firft applied : 
while, on the contrary, if it yields with 
difficulty, there will be reafon to fufpect 
that fome part of the head of the bone 
is fixed or locked in the upper part of 
the foramen ovale ; in which cafe the 
force in this direction fhould be difccn- 
tinued, and the other affiftants at the 
knee being directed to increafe the ex- 
tenfion downward, it will afterwards be 
more eafily raifed. 

In whatever direction the bone may 
be diflocated, this is the point requiring 
moft of our attention, to raife the head 
of the bone fufficiently before any at- 
tempt is made to force it into the focket. 

When 



264 Of Luxations of the Femur Gh.XL* 

When this is effected, a very flight force 
will in general draw it down when the 
diflocation is upward ; and when diflo* 
cated downward, whether it be fome- 
what backward or directly on a line 
with the focket, it will be eafily pufhed 
up. . 

In this manner recent luxations of 
this joint may for the mod part be re- 
duced ; and the fame treatment is perhaps 
the beft even in luxations of long dura- 
tion. In thefe it will fometimes fail ; but 
it will fucceed, I believe, as frequently as 
any other that has yet been propofed, 
while it is not productive of the dread- 
ful pain which commonly enfues from 
the ufe of fome of thofe machines that 
have been invented for making a greater 
extenfion of the limb. When any ad- 
ditional force, however, is judged to be 
neceflary, it may either be obtained by 
a proper application of Mr Freke's ma- 
chine reprefented in Plate LX XVIII. of 
Mr Petit's in Plate LXXVI. fig. 2. or of 
the pullies and ropes reprefented in Plate 
LXXV1I. 

It 



Seil. XIII. at the Hip-Joint. 265 

It fhould be remarked, however, that 
no afliftance of this kind can ever be ap- 
plicable where the luxation is down- 
ward. Extenfion of the limb having 
been confidered as neceflary in every 
variety of luxation, it has often been in- 
difcriminately employed, whether the 
head of the bone was placed above or be- 
low the focket : It is obvious, however^ 
that it is in the former only that it can 
ever prove ufeful j and in the latter, that 
much mifchief may enfue from it* 

The violent diftenfion of the mufcles* 
and extenfive laceration of the articular 
ligaments, with which luxations of this 
bone muft always be accompanied, ren- 
der much care and attention neceflary 
long after the reduction is accomplifh- 
ed. Local blood-letting with leeches* 
or cupping and fcarifying, proves parti- 
cularly ufeful here, and fhould be re- 
peated more or lefs frequently according 
to the violence of the fymptoms and age 
and habit of the patient ; and till the 
parts may be fuppofed to have recovered 

Vol. VI. § their" 



S66 Of Luxations Ch. XL, 

their tone, the patient Ihould be kept as 
much at reft as poflible. 
. By many it is imagined that the fe- 
mur may be partially luxated ; and the 
appearances which are fuppofed to arife 
from what is termed a Subluxation of 
this bone are defcribed by authors : Of 
thefe, however, I have taken no notice, 
as it is not my opinion that this bone 
can be partially luxated. The head of 
it is fo round, and the brim of the focket 
fo narrow, that whoever examines them 
with accuracy will be convinced that it 
cannot happen. The head of the bone 
may in a gradual manner be pulhed out 
of the acetabulum by a tumor [at the 
bottom of it, but I do not fuppofe that 
this can ever occur from external vio- 
lence. 



SEC 



Sea. XIV. of the Patella. 267 



SECTION XIV. 



Of Luxations of the Patella. 

HP HE patella may be either partially 
, or completely luxated, and it may 
be difplaced either upward or down- 
ward, outward or inward : It may alfo 
be luxated by itfelf, or it may be dif- 
placed along with the tibia and fibula in 
luxations of thefe bones. It cannot, 
however, be completely luxated in any 
direction, if it be not accompanied with 
a rupture of the ligament which ties it 
to the tibia, or of the tendon of the 
rectus mufcle connected to the upper 
part of it ; or perhaps of both : and it 
will be more readily diflocated inwardly 
than in any other direction, owing to 
the internal condyle of the femur being 
fomewhat lefs prominent than the other : 
S 2 for 



^68 Of Luxations Ch. XL* 

for as this bone is placed in fome de- 
gree between thefe condyles, it will 
necefTarily be moft eafily forced out at 
that fide where it meets with the leaft 
refiftance. 

Luxations of this bone are for the 
moft part eafily difcovered, as it is thin- 
ly covered with foft parts : But when it 
has been long difplaced, it is apt to induce 
fo much tumefaction, not only about the 
joint, but over all the contiguous parts, as 
to be diftinguifhed with difficulty. Even 
the moft partial luxation of the patella 
always gives confiderable lamenefs and 
much pain on every attempt to move the 
joint. 

In the reduction of a luxated patella, 
the patient mould be placed either on a 
bed or on a table, and his leg mould be 
ftretched out and kept in this pofture 
by an afliftant. The furgeon mould now 
lay hold of the bone and endeavour to 
pufh it into its fituation ; but inftead of 
pufhing it directly forward, it fhould 
fir ft be fome what raifed, otherwife we 

will 



Sea. XIV. of the Patella. 269 

will be apt to force it againfl the con- 
dyles of the femur or head of the tibia. 
The beft method of effecting this is to 
prefs down the fide of the bone mod 
diflant from the joint ; by which the op- 
pofite fide of it will be elevated, when a 
very moderate force will prefs it into its 
place. When the patella is drawn out 
of its fituation by the tibia and fibula 
being difplaced along with it, it cannot 
be replaced till the reduction of thefe 
bones is accomplifhedL 



SECTION XV. 

Of Luxations of the Tibia and Fibula at the 
Joint of the Knee. 

THE tibia is the only bone of the leg 
that is immediately concerned in 
the joint of the knee ; but as this bone 
cannot be diflocated without drawing the 
fibula along with it, we think it right to 
mention them together. 

S3 As 



2 7° Of Luxations of the Ch. XL. 

As more ftrength is required in the 
knee than in any other joint of the 
body, the bones of which it is chiefly 
formed, the femur and tibia, are con- 
nected together by the ftrongeft kind of 
articulation, namely by Ginglimus or 
the Hinge- like joint: the furfaces of the 
two bones are very extenfive, and they 
are firmly tied together by ftrong liga- 
ments : There is alfo reafon to fuppofe 
that the moveable cartilages placed 
between the ends of thefe bones have 
fome influence in lefTening the friction 
of the joint, and in thus rendering it 
more firm than it otherwife would be. 

The great ftrength of this joint is the 
reafon of its being lefs frequently diflo- 
cated than any other in the body: It 
cannot indeed be completely diflocated 
but by the application of fo much force 
as will not only rupure the teguments 
which cover it, but the ftrong ligaments 
and tendons which tie the bones to- 
gether. As this requires a very unufual 
degree of violence, thefe bones are fel- 

dom 



Sft. XV. Tibia and Fibula. 271 

dom forced entirely paft each other ; and 
the fame reafon even prevents them 
from being often partially luxated. 
When either a complete luxation, how- 
ever, or a partial one, is produced, it may 
happen nearly with equal eafe on either 
fide ; but the bones will be more readily 
forced backward than forward, owing to 
the flexor mufcles and tendons of the leg 
being much ftronger than the extenfors. 

The moil partial luxation of this joint 
is readily diftinguifbed, not only by the 
violent pain which it excites, and the 
lamenefs with which it is attended, but 
by the deformity which it produces, and 
which is always obvious on comparing 
both knee-joints together. 

When the patella is diflocated at the 
fame time with the tibia and fibula, it 
will for the moft part be reduced along 
with thefe bones ; but when this does 
not happen, it may be afterwards repla- 
ced in the manner we have mentioned 
in the laft Section. 

luxations of this joint are to be re- 
S 4. duced 



%"]i Of Luxations of the Ch.XLi 

duced by fixing the thigh with fufficient 
firmnefs, and extending the leg till the 
ends of the bones are entirely clear of 
each other ; when the tibia and fibula 
connected with it will be eafily replaced. 
In partial luxations, the degree of exten- 
fion neceflary for this will be inconfider- 
able ; but where the bones are complete- 
ly difplaced, more force will be required. 
It is fcarcely neceflary to obferve, that 
the mufcles of the leg fhould be as much 
relaxed as poflible while the force for 
extending it is applying. 

Scarcely any joint is fo apt to fufFer 
from inflammation as that of the knee ; 
fo that in all fuch injuries as this, where 
the furrounding foft parts are fo liable 
to inflame and become painful, the moft 
flricT: antiphlogiftic courfe becomes re-; 
quifite ; local blood-letting fhould be 
prefcribed, and repeated according to the 
violence of the fymptoms and flrength 
of the patient ; and the limb fhould for 
a confiderable time be kept at perfect 



Se&.XV. Tibia and Fibula, 27 % 

The upper end of the fibula, as well as 
the under extremity of it, is fometimes 
feparated by external violence from the 
tibia. As the fymptoms which this ex- 
cites are fimilar to thofe which occur 
from fprains of the mufcles, the real na- 
ture of the injury is often overlooked. 
It may almoft always, however, be di- 
ftinguifhed by an attentive manual exa- 
mination. The only method of obtaining 
relief is by replacing the bone, which 
for the moft part is eafily done, and re- 
taining it with a proper bandage till the 
parts have recovered their tone. 



SEC, 



.474 Of Luxations of the Ch.XL, 



SECTION XVI. 

0f Luxations of the Foot at the Joint of tht 
Ancle. 



TH E joint of the ancle is formed by 
the tipper part of the aftragalus or 
firft bone of the foot, being received in- 
to a cavity in the under extremity of the 
tibia ; which is bounded externally by the 
end of the fibula, projecting a confider- 
able way paft the end of the tibia. 

The aftragalus may be diflocated eU 
ther backward or forward, outward or 
inward, but is more frequently pufh- 
ed inward than in any other direction. 
The great ftrength of the tendo achillis 
prevents it from (lipping eafily backward, 
and it has alfo fome effect in preventing 
it from going forward. It cannot be 

puttied 



Sect.XVI. Foot at the Ancle. 275. 

pufhed outward without breaking the 
projecting end of the fibula. 

Diflocations of this joint are in gene- 
ral eafily difcovered by the pain and 
lamenefs which they produce, as well as 
by the obvious alteration which they oc- 
cafion in the appearance of the foot. When 
the aflragalus is pufhed forward, the foot 
appears to be lengthened and the heel 
fhortened ; when pufhed backward, the 
foot is fhortened and the heel lengthen- 
ed j and when luxated either outwardly 
or inwardly, there is always a preterna- 
tural vacancy on one fide of the joint 
and a prominency on the other. 

In the reduction of this luxation, the 
patient mould be placed either upon a 
table or on a bed, and the leg with the 
Imee bent ihould be firmly fecured by an 
afliftant or two. The foot is now to be 
put into that fituation which tends moft 
effectually to relax all the mufcles which 
belong to it ; and being given to an af- 
firmant, he mull: be defired to extend it 
in that direction till the moft prominent 

point 



%j6 Of Luxations of the Ch.Xl." 

point of the aftragalus has clearly palled 
the end of the tibia, when the bone will 
either flip into its place, or may be eafi- 
ly forced into it. 

As the upper part of the aftragalus is 
not perfectly round, but rather fomewhat 
hollow, this joint is more apt to be par- 
tially luxated than any other formed by 
a ball and focket, as this in fome meafure 
is : Partial luxations of it, however, arc 
eafily reduced. 

Beiides the ufual antiphlogiftic courfe 
which we have recommended to be ob- 
ferved after all luxations of the large 
joints, it is particularly neceflary in lux- 
ations of the ancle to keep the limb for 
a confiderable time at the moft perfect 
reft, efpecially where the under extremi- 
ty of the fibula is broke by the foot be- 
ing forced outward ; for as the liability 
of the joint depends in a great meafure 
on this bone, if it be not either rightly 
replaced or retained in its fituation till 
the cure of the fracture be effected, it 
may afterwards continue weak during 

life, 



Se&.XVI. Foot at the Ancle. 377 

life, or be attended with ftiffhefs and 
pain to a great height. Any weaknefs 
which fucceeds to injuries of this kind, 
if it be not removed by thefe meafures, 
will be moft effectually obviated by a 
firm fplint of thin iron connected with 
the fhoe, and applied along the outfide 
of the leg ; or by an inftrument invent- 
ed by the late Mr Gooch, reprefented in 
Plate LXXXIII. fig. 4. 



SECTION XVII. 



Of Luxations of the Os Calcis and other Bones 
of the Foot. 



r THE os calcis, which is the largeft 
bone of the foot, is fometimes diilo- 
cated laterally, where it is connected 
with the aftragalus. It is prevented 
from being pufhed forward by the other 
bones of the foot , and the tendo achillis, 

which 



-2^8 Of Luxations of the Ch.XL. 

which is inferted into a large rough pro- 
ceis of this bone, which projects back- 
ward and forms the heel, prevents it 
from being luxated in this direction. 

The aftragalus and os calcis are fome- 
times luxated at their junction with the 
os naviculare and os cuboides ; and as 
this joint, if it may be fo termed, is at 
no great diftance from the ancle, this va- 
riety of luxation has, in fome inftances, 
been miftaken for luxations of that joint. 
The foot may at this part be ' pufhed ei- 
ther outward or inward, or it may be 
forced directly downward : It will rare- 
ly be luxated upward, as it can fcarcely 
be expofed to external violence in fuch 
a direction as could have this effect. 

Luxations of any of thefe bones are 
readily difcovered by the pain and lame- 
nefi with which they are always attend- 
ed ; as well as by the alteration which 
they produce on the fhape of the foot. 

The os calcis, when displaced, is more 
difficult to reduce than almofl any other 
bone of the foot : It can only be done 

by 



Sect.XVII. Os Calcis, <&c. 279 

by fixing the leg and foot in fuch a pofi- 
tion as tends moft effectually to relax the 
different mufcles which belong to them ; 
and while they are in this position, by 
endeavouring to force the bone into its 
fituation ; and this will be more readily 
effected, if during the operation the foot 
be moderately extended. 

In luxations of the aflragalus and os 
calcis with the os naviculare and os cu- 
boides, as the anterior part of the foot is 
apt to be drawn towards the heel, it be- 
comes neceflary to extend it to fiich a de- 
gree as may clear the bones on the op- 
polite fides of the joint of each other ; 
for till this be done, the reduction can- 
not be effected, while the bones will im- 
mediately flip into their fituation as foon 
as they are drawn paft each other. 

The other three bones of the tarfus, 
ufually termed the Cuneiform Bones, as 
well as the Metatarfal Bones, and the 
Bones of the Toes, are all liable to be 
luxated, and they may be difplaced al- 
moft in every direction. But it is not 

neceflary 



2$o ®f Luxations, &>c. Ch. XL; 

necefTary to fpeak of the method of re- 
ducing them ; for the obfervations we had 
occafion to make on diflocations of the 
bones of the hand are equally applicable 
here : fo that we fhall now refer to what 
was faid on that fubjeft in theXIIth 
Section of this Chapter. 



CHAP. 



Ch.XLI. QfD'iftortedUmhs. 1%X 



CHAP. XLL 

O/'Distorted Limbs. 

LIMBS may be diftorted in various 
ways and by different caufes ; ei- 
ther from a morbid ftate of the bones* 
or from a contracted ftate of the mufcles,' 
or the bones and mufcles may both be 
affected. In fome cafes the distortion is 
owing to an original mal-conformation ; 
in others it occurs in infancy, and in 
fome at more advanced periods of life. 

For a confiderable time after birth the 
bones are foft and pliable, and are eafily 
affected by the poflures of the body. . The 
bones of the legs are apt to be crooked* 
by children being made to walk too ear- 

Vol. VI. T ly. 



282 Of Difiorted Limbs. Ch.XLI. 

ly. It is alio the effect of fome difeafes, 
particularly of rickets, to foften the bones 
fo much that they eafily yield to the 
pofture of the body, as well as to the or- 
dinary action of the mufcles. But the 
moft frequent caufe of diftorted limbs is 
that contraction of the flexor mufcles of 
the leg and fore-arm, which is often in- 
duced by an inflamed ftate of the knee 
and elbow, and of which we have a very 
common example in thofe cafes of white 
fwellirtg to which thefe joints are more 
particularly liable. As the limb lies 
eafieft while the mufcles are relaxed, the 
patient naturally keeps it always bent ; 
and when this pofture is long continued, 
it almoft cbnftantly terminates in fuch a 
rigid contracted ftate of the flexor ten- 
dons, as keeps the under part of the limb 
at an angle with the fuperior part of it : 
Of this we meet with daily inftances in 
the leg ; where from this caufe alone a 
patient is often altogether deprived of the 
ufe of his limb. 

As 



Ch. XLI. Of Bljlorted Limbs. 2 83 

As it has been a very prevailing opi- 
nion among practitioners, that little or 
no advantage can be obtained from any 
remedies that we may employ for dif- 
torted limbs, they have feldom made any 
attempt to cure them : In confequence 
of which this branch of practice has 
been almofl univerfally trailed to itine- 
rants or to profefled bone-fetters. In 
this, however, we are wrong ; and in fay- 
ing fo, I can fpeak with confidence from 
much experience in cafes of this kind : 
Having early in life obferved the mifery 
to which patients with diftorted limbs 
were reduced, I was refolved to make 
fome attempts for the relief of fuch as 
might apply to me, however fmall the 
chance might be of fucceeding ; and in 
various inftances I have had the fatisfac- 
tion of relieving, and in fome cafes of 
curing completely, patients who had 
been lame for feveral years, and where 
it was not expected that any thing could 
be done for their advantage. Where an 
anchylofis is formed by the ends of two 
T 2 bones 



a g 4 Of Diftorted Umbs, Ch. XLL 

bones forming a joint having adhered to- 
gether, it would be in vain to make any 
attempt to remove it, unlefs the inconve- 
niency attending it be very great: In 
which cafe, if it be the patient's defire, 
it may be a reafon for amputating the. 
limb j or in particular inftances, it may 
be removed by taking out the ends of the 
bones forming the joint, in the manner 
to be afterwards pointed out in the laft 
Section of Chapter XLIII. But when 
the ftifTnefs of a joint depends on a con- 
tracted ftate of the mufcles and tendons 
that ferve to move it, which is by much 
the mod frequent caufe of diftorted limbs, 
we my almoft in every inftance afford 
confiderable relief: And where a limb 
is crooked by a bone being bent, whether 
it may have happened from improper ma- 
nagement during childhood, or as the 
effea of rickets or any other difeafe, we 
may very commonly, by timeous atten- 
tion, either remove it entirely, or render 
it much lefs confiderable. 

Where a limb is diftorted from a ftiff 

con- 



Ch.XLI. Of Diftorted Limbs. 285 

contracted ftate of the imifcles and ten- 
dons which belong to it, a free ufe of e- 
mollients, with a moderate gradual ex- 
tenfion, is the remedy from which I have 
derived mod advantage, and which never 
in any inftance does harm. Thofe who 
have not been in the practice of ufing 
emollients for this purpofe, may imagine 
that they will not penetrate to the depth 
of the mufcles and tendons j and when 
I firft employed them, I mult own that I 
did not expect they were to do fo in any 
remarkable degree : But as I did not 
know any other remedy that was likely 
to lubricate fo effectually parts that were 
become ftiff, I was refolved to give them, 
a complete trial ; and I was foon convin- 
ced that the moft beneficial effects might 
be expected from them. In a former 
publication I had occafion to mention 
this, and fince that period various oppor- 
tunities have occurred of employing the 
fame remedy with advantage *. 

In order, however, to gain this end„ 
T 3 emol- 

* Vide A Treatife on Ulcers, &c. Part III. 



286 Of Diftorted Limbs, Gh. XLI. 

emollient applications muft be ufed in a 
very ample manner. All the contracted 
mufcles and tendons, from their origins 
to their infertions, mull be well rubbed 
with the emollient we are to employ for 
at leaft half an hour three times a day ; 
and the limb fhould be kept conflantly 
moift with, or as it were immerfed in, 
the emollient, by being covered with 
flannel well foaked in it at every repeti- 
tion of the frictions. While the frictions 
are applying, the limb fhould be flowly, 
tho' firmly, extended to as great a degree 
as the patient can eafily bear ; and the in- 
flrument reprefented in Plate LXXIX. fig. 
i. may be afterwards applied, in order 
to prevent the mufcles from contract- 
ing. 

It is neceflary, however, to remark, 
that the extenfion fhould not be made 
quickly: By doing fo, much mifchiefhas 
been often produced, infomuch that joints 
have become pained and inflamed, where 
there was not previoufly any other dif- 
eafe than fliffnefs of the flexor mufcles ; 

< - ■ ;.,,■■ " } 

while 



Ch.XLI. Of Diflorted Limbs. 2S7 

while it may be done with the utmoffc 
fafety in the flow gradual manner I have 
mentioned. In the one way, indeed, fe- 
veral months may be required for effect- 
ing what a greater force might accom- 
plish in as many weeks : but the latter 
mud always be attended with pain and 
hazard, while with the other we proceed 
with eafe and fafety. 

Even where extenfion is not neceffary, 
the effects of emollients are often con- 
fpicuous. We frequently meet with ftiff 
joints, particularly in the ancle, without 
any contraction or distortion of the limb. 
In this cafe, emollients alone, if duly 
perfifted in, will commonly anfwer the 
purpofe of relaxing them. 

Every kind of greafy application will be 
ufeful here, but animal fats prove more 
relaxing than vegetable oils, The greafe 
of geefe and ducks and other fowls an- 
swers well ; alfo hogs-lard, and the oil ob- 
tained from boiling recent bones of beef 
and mutton in water. Butchers ufually 
keep this pil in quantities : When pro- 
T4 pcrly 



OfDiftorted Limbs, Ch. XLI, 

perly prepared, it is quite pure and trans- 
parent, and has no ffnell. 

Where the diftortion of a limb pro 
ceeds from a bone being bent, if this 
is not of long duration, and efpecially 
when it occurs in childhood, we may 
very frequently be able to remove it by 
making a conftant preflure, gradually in- 
creafed, on the convex fide of the limb, 
till the bone is brought into its natural 
direction. 

This kind of deformity occurs fre- 
quently in patients labouring under 
rickets ; but we find it moft commonly 
in new-born children, either from an 
original mal- conformation, as we ob- 
ferved above, or from fome Angularity 
in the fituation of the child while in the 
womb. It is moft frequent in the legs, 
when it alfo affects the direction of the 
feet and ancles. When the bones of the 
leg are bent outward, the foot is turned 
inward ; and vice verja, the foot is turned 
outward when the leg is bent inward. 
Patients affected in this lafl manner are 

called 



Ch. XLI. Of DIJlorted Limbs. 289 

called Valgi, and Vari when the feet are 
turned inward. 

Thefe diftortions of the feet and ancles 
have been fuppofed to originate in al- 
moft every inftance from a mal-confor- 
mation of the joint of the ancle ; and 
the means that have been propofed for 
removing them, have been intended to 
effect an alteration of that joint : They 
may in fome cafes arife from this caufe, 
but I have fcarcely feen an inftance of it. 
At firfl view of the difeafe, we are indeed 
apt to imagine that the fault lies chiefly 
in the ancle ; but it will be very univer- 
fally found, on a more narrow infpec- 
tion, to proceed from the form of the 
leg. When the leg is bent outward, the 
toes are turned inward, and the fide of 
the foot downward ; or if the curvature 
of the leg be confiderable, the fole of 
the foot will be turned nearly altogether 
upward, while the top of the foot will 
reft on the ground on every attempt to 
walk : And on the contrary, when the 
bones of the leg are bent inward, the 

toes 



zqo OfDiftorted Limbs. Ch. XLI. 

toes and fole of the foot will be turned 
outward and upward. 

Whoever will examine with attention 
the effect produced upon the foot by the 
bones of the leg being curved in the 
manner I have defcribed, will find that 
the maladies we are new coniidering 
muft necefTarily refult from it : And al- 
though it may happen, in a few cafes, 
that the joint of the ancle is affected by 
a long continuance of the diftortion, yet 
in almoft every inftance the difeafe will 
be found to proceed originally from the 
caufe I have mentioned : fo that in the 
management of the diforder, our views 
fhould be chiefly directed towards this 
affection of the leg. By removing the 
curvature of the bones, the foot will 
gradually regain its natural fituation, 
while all our endeavours will prove 
fruitlefs if we only attempt to alter the 
direction of the ancle-joint. 

When cafes occur of the foot and toes 
being turned inward, folely from a malr 
conformation of the ancle-joint, it will 

no 



Ch.XLI. Of Dijlorted Limbs. 39 J 

no doubt be neceffary to endeavour to 
give the joint a better direction j but as 
I never met with an inftance of this, I 
muft leave the particular mode of effect- 
ing it to thofe who may happen to fee it. 
The eafieft and molt effectual way of 
applying preflure to the bones of the leg 
when bent, is by fixing a firm fplint of 
iron in the fhoe, on the concave fide of 
the leg : and if the head of the fplint be 
made to reft againft the corresponding 
condyle of the femur, and the other end 
of it upon the foot, an eafy gradual 
preflure may be made upon the oppofite 
fide of the leg by one or two broad 
flraps paffed round both the leg and the 
fplint. If the fplint is covered with foft 
leather and properly fitted to the parts, 
it gives no uneafinefs ; and by drawing 
the flrap furrounding it and the leg a 
little tighter from time to time, the pref- 
fure will be increafed in the gradual 
manner I have mentioned. In Plate 
LXXXIII. an apparatus is reprefented ; 
which in one cafe, where the curvature 
of the leg was very confiderable, and 

where 



2$ 2 Of Diflorted Umts. Ch. XLT. 

where the fole of the foot was turned 
almoft entirely upwards, anfwered the 
purpofe very completely. It is fome- 
tim.es fufficient to fix the fmall end of 
the fplint in the ihoe, and the broad flat 
pad at the top on the condyle of the fe- 
mur. A fplint for this purpofe is repre- 
fented in fig. 2. This gives it two fixed 
points, by which we have it in our 
power to make any neceflary preffure 
with the (traps paned round the leg : but 
in fome inftances, as in the one I allude 
to, the fole of the foot cannot be kept 
fo much down as to admit of this, 
without fixing the fhoe to a frame, as 
is reprefented in fig. 3. for in every 
cafe of this nature, the fole of the foot 
ihould be kept as much as poflible in a 
natural fituation, otherwife the preffure 
made upon the leg for removing the cur- 
vature in the bones will be apt to give a 
wrong direction to the joint of the ancle 
by the under end of the fplint, which in 
this cafe mufl be made to reft upon it. 
J have thus given a general view of 

the 



Tlaik LXXXit 



TIG.T- . 




Ch.XLI. Of Dlflorted Llmhs. 293 

the idea I entertain of the nature of this 
affection, and of the management beft 
adapted for removing it: But whether 
limbs be diflorted from a contracted flate 
of the mufcles belonging to them, or 
from a curvature in the bones, much 
variety muft occur in the application of 
the remedy, particularly in the manner 
of applying the exteniion. The treat- 
ment, indeed, which fuits one cafe is 
feldom exactly applicable to another ; . it 
muft therefore be varied according to 
the judgment of the practitioner. 

Other modes have been propofed for 
removing curvatures in bones : Of thefe 
the beft I have feen is an invention of an 
ingenious artift of this place, Mr Gavin 
Wilfon, who has long been much em- 
ployed in this branch of bufinefs. In 
Plate LXXXII. fig. 1. and 2. I have re- 
prefented one of Mr Wilfon's inftruments 
for diftortions of the leg. 



CHAP. 



294 °f Di/lortions £h. XLII; 

CHAP. XLIL 
Of Distortions of the Spike. 



THE fpine may be diftorted in various 
directions, outwardly, inwardly, 
and laterally ; and in fome cafes we 
meet with it in all thefe directions at 
the fame time, and in the fame perfon. 
This fometimes arifes from external vio- 
lence ; but it is more frequently a fyrnp- 
tom of a weakly, delicate conflitution. 

Befides the deformity which thefe dif- 
tortions produce, they are very apt to in- 
jure the health, by compreffing the ab- 
dominal and thoracic vi/cera, and by in- 
ducing paralytic affections of the lower 
extremities, from the prefTure which they 

make 



Ch.XLII. of the Spine. ig$ 

make upon the nerves which fupply thofe 
parts. They occur in all ages ; but more 
frequently about puberty than at any 
other period, and more commonly in girls 
than in boys. In general, the effects 
which refult from them are obferved be- 
fore the caufe is fufpected ; for there is 
feldom much pain in the part immediate- 
ly affected* 

When diftortion of the fpine occurs 
during infancy, the patient appears to be 
fuddenly deprived of the ufe of his limbs ; 
but at more advanced periods, he com- 
plains for fome time of feeblenefs and 
languor, and of numbnefs or want of 
feeling in the under extremities. By de- 
grees this want of fenfibility is found to 
increafe ; and he is often obferved to (tum- 
ble and to drag his legs inftead of lifting 
them cleverly, nor can he ftand erect: for 
any length of time but with much diffi- 
culty. At lafl he lofes the ufe of his legs 
entirely, which become altogether para- 
lytic ; and when the fpine is diftorted 
much forward, fo as to comprefs the vif- 

cera 



$96 Of Dlflortiom Ch.XLtl 

cera of the thorax or abdomen, he be- 
comes diflrefTed with dyfpnaea, or com- 
plaints in the ftomach and bowels, ac- 
cording to the part of the fpine that is 
affected. 

In fome cafes the lofs of power in the 
extremities takes place in the courfe of 
a few days from the firft approach of the 
difeafe ; and it fometimes becomes gra- 
dually lefs remarkable, although it never 
is, fo far as I have obferved, entirely re- 
moved. 

When the deformity in the back is 
difcovered, we fometimes find that one 
of the vertebrae only is difplaced : on 
other occafions two or more are affected ; 
and in fome cafes there is reafon to ima* 
gine that it arifes folely from a thicken- 
ing of the ligaments which connect: the 
vertebrae together, without any particu- 
lar affection of the bones. When one 
of the vertebrae only is affected, it is ob- 
ferved that the patient is more complete*- 
ly deprived of the power of his limbs 
than when two or more of them are dif- 
placed, owing perhaps to the angle being 

more 



, ' l " v " : IA * x,,l -(H 




Ch. XLII. X)fthe Spine. 297 

more acute, and confequently the pref- 
fure on the medulla fpinalis greater when 
one bone only is thrown out of the range. 
This alfb accounts for the paralytic 
fymptoms in fome cafes becoming lefs re- 
markable in more advanced ftages of the 
flifeafe than they were at firfi ; for al- 
though one bone only is fometimes dis- 
placed at nrft, yet one or both of the 
contiguous vertebrae almoft conftantly 
yield at laft ; and the difference which 
this occafions is fo great, that patients al- 
moft always linger and die in the courfc 
of a year or two, often in lefs time, when 
one bone only is deranged ; while they 
live for a great length of time, frequently 
as long as if no fuch circumftance had 
occurred, when the curvature of the fpine 
becomes more extenfive. 

As diftortions of the fpine often pro- 
ceed from delicate weakly patients in- 
dulging too much in particular poftures, 
every habit of this kind fhould be rigid- 
ly guarded againft on the firft appear- 
ance of the diforder. If the patient has 

Vol. VI. U been 



298 Of Diflorttons Ch.XLIt 

been accuftomed to lean much to one 
fide, the reverfe of this mould be advifed • 
and that the body may lie as much as 
poflible upon an equal furface during 
fleep, he ought to ufe a hair matrefs laid 
upon boards inftead of a feather or down 
bed. 

By attention to thefe points \ by the 
ufe of an invigorating diet ; the cold 
bath, bark, and other tonics ; the difor- 
der has been in fome cafes prevented 
from advancing £0 far as it otherwife pro- 
bably would have done : but where any 
of the bones have been affected, I have 
never feen an inftance of a complete cure 
being obtained. Mr Pott, to whofe ob- 
fervations upon this fubject we are much 
indebted, fpeaks highly of the effect of 
drains placed as near as poffible to the 
tumor. He advifes an iffue to be opened 
with cauftic on each fide of the tumor, 
large enough to admit a kidney-bean, and 
the bottom of the fore to be fprinkled 
from time to time with powder of can- 
tharides. This I have pra&ifed in vari- 
ous 



{ 



Ch. XLII. of the Spine. , 299 

ous cafes, and in fome inftances with ob- 
vious good effects : But in all of thefe 
there was reafon to fuppofe that the feat 
of the diforder was in the ligaments, and 
not in the bones of the fpine. When 
they have appeared to prove ufeful where 
the bones have been affected, I conclude 
that the mitigation of fymptoms has 
arifen from the caufe I have mentioned, 
the prefTure upon the fpinal marrow be- 
ing leffened in the progrefs of the dif- 
order. 

Various machines have been invented 
for the removal of diftortions of the 
fpine by preffure : All of thefe, however, 
do harm, and ought never to be ufed. It 
muft at once appear, to whoever is ac- 
quainted with the anatomy of thefe parts, 
and with the nature of this difeafe, that 
the difplaced bone is never to be pufhed 
into its fituation by any amftance of this 
kind ; and if this cannot be accomplished, 
it is obvious that no advantage is to be 
derived from the practice, while it is evi- 
U a dent-' 



30© Of Diflortions % Zfc. Ch. XLII, 

dent that much mifchief may enfue from 
it. 

In all diftortions of the fpine, it is an 
object of the firft importance to fupport 
the head and moulders. If this be not 
duly attended to^ the weight of the head 
tends almoft conftantly to increafe the 
diforder. The collar ufually employed 
for this purpofe anfwers nearly as well 
'as any other. In Plate LXXXVIII. fig. i. 
a reprefentation is given of one with 
Ibme improvements, by which both the 
head and moulders may be very effectu- 
ally fupportcd ; and in fig. 3. another is 
delineated for fupporting the moulders 
only. 



CHAP. 



Sett. I. Remaks on Amputation. 301 



CHAP. XLIII. 

O/Amputation. 



SECTION t 

General Remarks on the Operation of ' Amputa- 
tation, 

BY the term Amputation, we ufually 
underftand the removal of a limb. 
We fpeak of the Extirpation of a tumor ; 
of the mamma ; of a teftis : but we fay 
the Amputation of a leg and of an arm. 

The mutilation, which is a confequence 
of this operation, renders it one of the 
mpft dreadful in the pranfliee of furgery j 
yet as the only means by which life can 
jt>e faved, it is frequently neceflary. It is 
V $ an 



302 Remarks on Amputation. Ch. XLIII. 

an operation, however, fo repugnant to 
humanity, fo diftrefsful to the unfortu- 
nate fufFerer, and in fome circumftances 
fo fraught with danger, that nothing but 
a clear conviction of this neceffity can 
warrant our propofing it in any cafe. 

The operation indeed is not difficult : 
every practitioner accuftomed to handle 
inftruments may perform it. But to dif- 
tinguifh with precifion the cafes which 
require it, from thofe which might do 
well under a different treatment, and 
to determine the particular periods of 
each when it ought to be performed, are 
circumftances which require more delibe- 
ration than perhaps any other in furgery : 
We lhall therefore enumerate the caufes 
which may make amputation neceffary, 
before proceeding to defcribe the method 
of performing it. 



SEC- 



I 



Bed. II. Of Caufes, &fc. 30; 



SECTION II. 

Of the Caufes which may render Amputation 
necejfary. 

THIS operation may be rendered ne- 
cefTary by various caufes ; all of 
which may be comprehended under the 
following heads. 

1. Bad compound fractures. 

2. Extenfive lacerated and contufed 
wounds. 

3. A portion of a limb being carried off 

by a cannon-ball, or in any other man- 
ner, if the bones be unequally broke 
and not properly covered. 

4. Extenfive mortification. 

5. White fwellings of the joints. 

6. Large exoflofes, whether they be con- 

fined to joints, or fpread over the whole 
bone or bones of a limb. 

u 4 ' % 



304 OfGaujks that render, Ch. XLIII. 

7. Cafes of extenfive caries, accompanied 

with bad ulcers of the contiguous foft 
parts. 

8. Cancer, and fome other ulcers of an 
inveterate nature. 

9. Various kinds of tumors. 

10. Particular diftortions of a limb. 
Each of thefe caufes we mall confider 

in the order they are here mentioned. 

In Chapter XXXIX. SetfionXV. wehad 
pccafion to fpeak particularly of compound 
fractures : I mall at prefent therefore only 
remark, as the fubftance of what was then 
fully pointed out, that in the army and 
navy, where ordinary patients cannot be 
duly attended, and where they mud be 
much jolted, and often removed from 
place to place, immediate amputation 
fhould be advifed in cafes of compound 
fractures that are in any degree formida- 
ble. Cafes will often indeed occur in 
the worfl fituations, in which it will be im- 
proper to amputate the limbs. Thus, in a 
compound fracture, where little violence 
feas been done, and where the bones have 

b>eer^ 



Sect.II. Amputation neteJfaYy. 303 

been broke fo much in a tranfverfe di- 
rection, that when replaced, they fup- 
port each other with firmnefs, and efpe- 
cially if one bone only is broke, it would 
no doubt be a fevere, and often an un- 
necefTary meamre, to propofe the removal 
of the limb. But whenever much vio- 
lence has been done to a limb ; when the 
bones are broke in fuch a manner that 
they do not, even when exactly replaced, 
fupport each other firmly ; in all fuch fi- 
tuations, I believe, it would be a good 
general rule to advife immediate ampu- 
tation. Unlefs the operation, however, 
can be performed foon after the accident, 
it cannot again be admiflible for a con- 
siderable time ; for whenever a limb has 
become fwelled and inflamed, it can ne- 
ver, but with the utmoft danger, be ta- 
ken off till thefe fymptoms fubfide. 

In private practice, however, where 
the patient can from the firft be placed 
in an eafy comfortable Situation, from 
which he need not be removed till his 
pire be completed ; where he can be 

kept 



%o6 OfCaufcs that render- Ch.XLIII. 

kept perfectly quiet, and have all the 
advantages of good air, a proper regi- 
men, and the affiftance of able practi- 
tioners, very few cafes will occur in 
which amputation fhould be advifed. 
The only caufe, as I have obferved elfe- 
where, which in fuch circumflances can 
render immediate amputation proper, is 
the bones of a limb, together with the 
mufeles and other foft parts with which 
it is covered, being fo mattered and 
bruifed that there will be no chance of 
the limb being rendered ufeful by any 
attempt that might be made to fave it : 
In fuch circumflances it mould be re- 
moved immediately ; but this not being 
done, the operation, as we have obferved 
above, muft be delayed, till the fwelling, 
inflammation, and fever induced by the 
accident, be removed. 

Although early amputation, however, 
is feldom neceflary in private practice, 
yet, in the after treatment of compound 
fractures, it is fometimes proper : 

j. In confequence of profufe haemor- 

rhagies, 



Sect.II. Amputation necejfary. 2>°7 

rhagies, which cannot otherwife be flop- 
ped. Thefe fometimes happen from 
one or more arteries being cut by the 
ends of the fractured bones, as well as 
from other caufes. 

2. In confequence of extenfive mor- 
tification. This we fhall have occafion 
to confider more particularly when we 
fpeak of mortification as one of the ge- 
neral caufes of amputation. 
• And, 3. By the ends of the fractured 
bones remaining long difunited, attended 
with the difcharge of fuch large quanti- 
ties of matter, that the patient runs fome 
rifle of finking under it. 

We have elfewhere obferved, that frac- 
tures are fometimes prevented from unit- 
ing, by a loofe portion of bone being 
left which ought to have been removed ; 
and nothing more readily keeps up a 
prof life difcharge -• of matter : But when 
all fuch pieces of bone have been re- 
moved, when no union takes place, or 
when the difcharge ftill continues in fuch 
quantities as to weaken the patient, 
notwithftanding every thing that can be 

done 



$o8 OfCaufes that render Ch.XLIlI. 

done to prevent it ; fuch as preferving 
the limb fteadily in one pofture, regular 
dreffing of the fore as often as may be 
neceflary, a nonrifhing diet, and a plen- 
tiful ufe of bark ; nothing will in fuch 
circumftances Co certainly fave the pa- 
tient as the removal of his limb. 

We mentioned extenfive laceration 
and contufed wounds as the fecond ge- 
neral caufe of amputation. Wounds not 
accompanied with fractures of the con- 
tiguous bones are feldom fo bad as to 
require amputation in any ftage of them : 
But when a limb is fo feverely lacerated 
or contufed as to have all the large 
blood-veffels belonging to it deftroyed, 
fo as to leave no ground of hope that 
the circulation can be preferved in if, 
immediate amputation Ihould be advifed, 
whether the bone be fafe or not. As in 
fuch circumftances no effort on the part 
Gf the practitioner could fave the limb ; 
and as wounds of this defcription are 
more apt to terminate in mortification 

than 






Seel. II. Amputation necejfarp 309 

than any other, the fooner the operation 
is performed the better. 

It will alfb happen in lacerated and 
contufed wounds, that amputation may 
afterwards be rendered neceffary, al- 
though it did not appear to be fo at 
firft. In this refpect they are fimilar 
to compound fractures ; and the fame 
obfervations will apply to them. He- 
morrhagies may occur which cannot be 
flopped ; extenfive mortification may 
take place ; and fuch large quantities of 
matter may form, that the patient will 
not be able to bear up under the di£- 
charge. In any of thefe events, we have 
to confider the removal of the limb as 
the only remedy. 

The removal of a portion of a limb by 
a cannon-ball or other violence, we men- 
tioned as the third general caufe of am- 
putation. 

This is one of thofe cafes which many 
contend can never require amputation : 
for the limb being already removed, it 
will be better, they allege, to endeavour 

*to. 



3 1 o Of Caufcs that render Ch. XLIll, 

to heal the fore, than to add to the pain 
and danger of the patient by an opera- 
tion. The argument is plaufible, but it 
will not bear examination. 

In wounds of this kind the bones are 
commonly much mattered, and even 
fplintered ; and the mufcles and tendons 
are left of unequal lengths, and much 
lacerated and contufed. In this fituation 
it is allowed by all, that the feparate 
pieces of bone, as well as the fharp ends 
of the remaining bone, mould be re- 
moved, together wth the ragged ex- 
tremities of the mufcles and tendons. 
Now all this could feldom, I believe, be 
done in lefs time than the operation it- 
felf ; while by amputating above the in- 
jured part, and by covering the bone 
with found mufcles and fkin, we diminifh 
the fore ib much that it will probably 
heal in a third part of the time that the 
original wound would have required ; 
at the fame time that the patient will 
have a good flump, which in the other 
method he never could have. With me 

this 



Sect. II. Amputation necejjary. 311 

this argument of itfelf would be fufEci- 
ent for advifing the operation under the 
circumftances we are defcribing : for as 
I do not fuppofe it would add to the pa- 
tient's rifk, any additional momentary- 
pain it might occafion would be amply 
compenfated by the advantage he would 
afterwards derive from it. When the 
practitioner has it in his power, the 
operation fhould be advifed immediate- 
ly : for, however neceflary it might be, 
many patients would not afterwards 
have fufficient firmnefs of mind to fub- 
mit to it; and, from ignorance of the 
advantages to be derived from it, would 
prefer prefent eafe, to future convenien- 
cy and advantages, however great they 
might be. 

4. Mortification is the next caufe we 
have to confider by which amputation 
may be rendered neceflary. They who 
are determined to oppofe the practice of 
amputation as much as poflible, affect: to 
confider it as unneceflary in mortifica- 
tion : for all the lefTer degrees of it, tjiey 

obferve. 



%\1 Of Caufes that render Ch. XLIlt 

obferve, may be cured ; and when very 
extenlive, that the patient will common- 
ly fall a facrifice to the difeafe, whether 
the operation be performed or not. This 
opinion, however, is fo directly contrary 
to fact, and to the experience of every 
unprejudiced practitioner, that we lhall 
not attempt to refute it : for although it 
would be highly improper to advife the 
removal of a limb in flight degrees of 
gangrene ; yet when it has fpread fo ex- 
tenfively as to deftroy all or even a great 
proportion of the foft parts of a limb, 
an occurrence too frequently met with, 
what remedy could b.e employed inftead 
of it ? As I know of none, and as I 
never heard of any which could in any- 
way prove ufeful, I mail conclude, that 
in mortification proceeding to fuch an 
extent as we have mentioned, amputation 
of the limb becomes indiipenfable. 

But although this doctrine will be ge- 
nerally admitted, yet practitioners are 
not agreed with refpect to the period of 
mortification at which the operation 

mould 



Sect. II. Amputation necejfary. 313 

fhould be performed. Some contend, 
that in almoft every cafe of gangrene, 
and efpecially where it arifes from ex- 
ternal violence, the limb mould be am- 
putated as foon as mortification is evi- 
dently formed, and while it continues to 
fpread : Others are of opinion, that am- 
putation fhould never be advifed till the 
gangrene is not only flopped, but till the 
gangrenous are feparated from the re- 
maining found parts. 

Thofe who advife immediate amputa- 
tion obferve, that by taking the limb off 
above the difeafec^ part, we may prevent 
the progrefs of the mortification, and 
may thus faVe the patient's life. Altho' 
the argument is fpecious, it does not ap- 
pear to be well founded ; and fo far as 
my obfervation goes, I would fay that it 
is a practice fraught wi£h danger, and 
ought univerfally to be difcarded : For 
however attentive we may be in ampu- 
tating at a part of the limb which ap- 
pears to be- found, even the moft expe- 
rienced practitioner will be liable to be 

Vol. VI. X de^ 



3'f4 Of Caufcs thai render Ch. XLIII. 

deceived. The fkin may be perfectly 
found, and may be free from pain, in- 
flammation, and fwelling ; and yet the 
deep-feated mufcles and other parts con- 
tiguous to the bone may be in a ftate 
of gangrene. Of this I have feen diffe- 
rent inflances : But even where the whole 
divided parts are found to be altogether 
found, if the operation is performed while 
mortification is advancing, the difeafe 
fcarcely ever fails of feizing the flump ; 
at lead I never knew an inftance of the 
contrary, and I have unfortunately hap- 
pened to be concerned in different cafes 
where this practice was adopted. On 
converting with practitioners, who, from 
peculiarity of fituation, have much em- 
ployment in thofe accidents which are 
mofl apt to terminate in gangrene, I 
alfo find that their experience tends 
to fupport this opinion : It was alfo 
the decided opinion of the late Mr 
Shar.pe, as it is of Mr Pott, and of every 
modern practitioner of obfervation *. 

I 

* Mr Pott's words upon this point are very ftrong: 

«I 



Sect. II. Amputation neccjfary. $ 1 5 

I think it right to mention this, as at- 
tempts have of late years been made 
by fome fpeculative practitioners to in- 
troduce a contrary practice ; which if 
admitted, there is much reafon to fufpect 
would prove extremely hurtful, although 
from its proving fo univerfally unfuccefs- 
ful, there is reafon to hope that it will 
foon be laid afide, even by thofe who at 
prefent patronize it. 

I would not think it neceffary, how- 
ever, to delay the operation fo long as is 
advifed by fome practitioners, and par-* 
ticularly by Mr Sharpe ; who thinks that 
it fhould never be performed till the fe- 
paration of the mortified parts is con- 
fiderably advanced *. As Mr Sharpe was 
a man of much experience, his obferva- 
tion may prove to be well founded ; but 
X 2 fo 

" I have more than once feen the experiment made of 
" amputating after a gangrene has been begun ; but 1 
"never faw it fucceed : — It has always hurtiedthe 
,c patient's destruction." — Fide Remarks on Fractures, 
&c. 

* Fide Treatife on the operations of Surgery, Chap, 
XXXVII, 



3 i6 Of Caufes that render Ch. XLIIT.. 

fo far as I have yet feen, I would conn- 
der it as fufficient to wait till the mor- 
tification is fairly flopped, but not much 
longer : In this manner, we feem to reap 
all the advantages which the caution we 
have advifed can give ; and the earlier 
after this that the mortified parts are 
removed, the more readily will we pre- 
vent the fyftem from fuffering by the ab- 
forption of that putrefcent matter which 
a gangrenous mafs univerfally yields. 

The opinion we have given relates to> 
every variety of gangrene. In whatever 
way it may have arifen, the practice 
mould be the fame : for although fome 
ftrefs has been commonly laid upon the 
circumflance of its proceeding from art 
internal or external caufe, yet no utility is 
derived from this. The operation mould 
in no inftance be advifed till the period 
we have mentioned ; and at that time,, 
whatever may have been the caufe of the 
difeafe, no delay mould be admitted. 

5. In mentioning white fwellings of 
the joints as a caufe of amputation, we 

muft- 



Sect. IT. Amputation necejfary. 317 

muft refer to a former publication for 
the management of the difeafe, as well 
as for a more particular account of thofe 
fymptoms which more efpecially indicate 
the operation *. At prefent we have on- 
ly to obferve, that as long as there is the 
leaft reafon to hope that by any means 
the limb may be faved without hazard to 
the patient, the operation fhould never 
be advifed. As a farther motive for 
this, I may remark, that the opinion I 
gave in the treatife alluded to above, 
has been greatly confirmed by much ex- 
perience, namely, that amputation more 
frequently fucceeds, that is, a greater 
proportion recover from the operation 
when it is delayed till the patient is con- 
siderably reduced by the difeafe, than 
when it is performed in the more early 
ftages of it. The caufe of this may be 
nearly the fame as what we have given 
above, when advifing late Amputation in 
cafes of Compound Fractures. 

X 3 6. In 

* Viie Treatife on the Theory and Management of 
Ulcers, fee. Part IIL 



3 1 8 Of Gaafes that' render Ch. XLIII. 

6. In one of the preceding Chapters, 
we have entered upon the confederation 
of the various kinds, of exoftons * ; fo that 
at prefent we have only to remark, that 
when a difeafed portion of bone cannot 
be taken out in the manner we have for- 
merly advifed, and when the tumor is 
either hurting the patient's health or has 
become unfupportable from its fize or 
any other circumftance, amputation of 
the limb, when no particular reafon pre- 
vents it, mould be advifed as the only 
remedy. 

The next caufe we have mentioned 
by which amputation may be rendered 
neceffary, is an extenfive caries attended 
with ulcers of the contiguous foft parts. 
When fpeaking of caries, in the feventh 
Secuon of the Treatife on Ulcers, we 
pointed out the different means employ- 
ed for the cure of the difeafe, that is, for 
promoting an exfoliation of the difeafed 
part of the bone. In addition to what 
we had then occafion to fay, it may be 

ob~ 

* Fide Chapter XXXV1I1, Station III. § iy 



Sect. II. Amputation nccejfary. 319 

obferved, that although an extenfive caries 
is in general confidered of itfelf as a iuf- 
ficient reafon for amputating a limb, yet 
it certainly mould be admitted under 
much reftriction. However extenfive a 
caries may be, even although it occupies 
the whole length of a bone, it may be 
removed ; and we have many inftances 
on record of deficiencies produced in this 
manner being amply fupplied by, a rege- 
neration of bone : So that where the con- 
ftitution is found, and more efpecially 
when the patient is young, a carious 
bone will' feldom of itfelf prove a fufE- 
cient motive for removing a limb, at leaft 
the chance of faving it by removing the 
difeafed bone mould firft be given, But 
when a carious bone is conjoined with 
deep and extenfive ulcers of t,he cor- 
refponding foft parts, which might 
give much caufe to fufpedl that a cure 
would not be obtained even although 
the difeafed bone mould be taken out, 
amputation mould be preferred ; for in 
this fituation, befides the difficulty of 
X 4 healing; 



320 Of 'Caufes that render, Gh. XLIII. 

healing the fores, the formation of any 
confiderable quantity of bone would be 
rendered very uncertain, and therefore 
the rifk mould not be incurred. 

8. The next caufe we have to advert to, 
by which amputation may be rendered 
neceffary, is cancer, and fome other ul- 
cers of an inveterate nature. 

When fpeaking of Cancer in the Trea- 
tife on Ulcers, we endeavoured to fhow, 
that no dependence is to be placed either 
upon internal medicines or outward ap- 
plications in the treatment of it ; and 
that the removal of the difeafed part is 
alone to be trufted. It mufl be acknow- 
ledged that cancer does not frequently 
occur on any of the extremities : but every 
practitioner mufl have feen it on diffe- 
rent parts of them ; and wherever it ap- 
pears, the removal of the difeafed parts 
with the knife fhould be advifed immedi- 
ately. They may be often taken away 
without amputating the limb ; but when 
the diforder has proceeded fo far as 

to 



Sect. II. Amputation neceffary* 32 \ 

to attack the ligaments or bones, and 
efpecially when the fore is extenfive, 
nothing but the removal of the limb a- 
bove the parts that appear to be affected 
can be depended on. In fuch circum- 
ftances, I have known attempts made to 
fave the limb, but always without ftic- 
cefs. Even the removal of the limb will 
fometimes fail ; but I have known it 
prove effectual where the difeafe had re- 
turned, after being removed in the ufual 
way. 

Befides cancer, other ulcers may, in 
particular circurnflances, render ampu- 
tation neceffary : Where an extenfive 
ulcer, not induced by any general affec- 
tion of the fyftem, is hurting the health 
of a patient ; and when, inflead of yield- 
ing to the remedies employed, it becomes 
evidently more extenfive and more in- 
veterate, as it might at laft proceed fo 
far as to endanger life ; we ought rather 
to advife the limb to be taken off. Such 
ulcers as are ufuaily termed Phagadenic, 
fometimes terminate in this manner : 

But 



322 OfCaufes that render Ch.XLIIL 

But this termination is moft frequent in 
finuous ulcers ; fuch as arife from deep- 
feated abfceffes, where the matter has 
found accefs between the interftices of 
the large mufcles, and where, notwith- 
ftanding our endeavours to accomplifh 
a cure, the difcharge continues to be fo 
profufe as to endanger t.he life of the pa- 
tient. 

9. The next caufe we have mentioned 
which may require amputation, is vari- 
ous kinds of fwellings. 

Encyfted tumors feldom lead to this 
neceflity ; but in fome inftances where 
they are deep-feated, originating perhaps 
from the periofteum, if they are allow- 
ed to remain till they acquire a great 
bulk, all the contiguous parts come to be 
fb injured by them, that nothing but the 
removal of the limb will anfwer any 
falutary purpofe. In fome cafes, by 
a long continued preffure, the contigu- 
ous bones are not only rendered carious, 
but are altogether diflblved ; at the fame 
time that the cellular fubftance, and even 

the 



Sect; II. Amputation neceffary. 323 

the mufcles of the limb, become fo much 
difeafed as to give no caufe to hope that 
we could be able to fave them. 

We fometimes find a portion of a limb 
confiderably enlarged with an uniform 
hardnefs in fome parts, and in others 
with a degree of foftnefs which gives 
caufe to fufpect that a fluid of fome kind 
or other is collected beneath. The fkin 
at firft retains its natural colour ; but at 
laft it acquires a livid hue. The com- 
mencement of the difeafe is not attended 
with pain ; but at laft it not only be- 
comes painful, but extremely trouble- 
fome from its weight. It ufually arifes 
without any evident caufe, and often in 
people who are otherwife healthy : At 
firft the fwelling commonly appears on 
the inferior part of a limb, and proceeds 
gradually up till it occupies the whole 

of it. 

1 

Swellings of this kind are at firft often 
miftaken for common cedema or anafar- 
ca ; and they feem to be fo far of this na- 
ture, that they are evidentlv produced 

by 



324 Of Caufes thai render Ch. XLIIL 

by an effufion into the cellular ftib- 
itance : but inftead of being of the ferous 
kind, the effufed fluid is found to be 
tinged with blood, and of an acrimoni- 
ous nature ; at leaft this has been the 
cafe in all that I have known opened ; 
and it has like wife happened, that the 
matter has never been difcharged in fuch 
quantities as to have much influence on 
the fize of the tumors, the fwelling 
ufually remaining of nearly the fame 
bulk after the operation as before it: 
Hence no advantage is derived from it; 
on the contrary, the operation always 
does harm. A painful fore is produced j 
and it always accelerates the progrefs of 
the tumor. Indeed, nothing I have ever 
known employed has any effect, in re- 
tarding it ; fo that I confider amputation 
as the only refource, whenever the tumor 
has become fo large as to create any ma- 
terial uneafinefs. Whether this will always 
prove effectual or not, I cannot pretend 
to fay ; but hitherto I have met with no 
inftance of the difeafe returning where 

am- 



Sect. II. Amputation necejfary. 325 

amputation was performed on a found 
part of the limb. 

Swellings of the aneurifmal kind have 
alfo been confidered as a caufe which, in 
particular fituations, may give rife to 
amputation. This has originated from 
the operation for the aneurifm having 
failed in different inftances when per- 
formed upon the crural artery, and from 
the amputation of the limb having in 
fimilar affections faved the life of the 
patient. Where an aneurifm in the 
ham, or on the thigh, is very large, and 
has been of fuch long duration as to 
hurt the texture of the foft parts, as well 
as to injure the bone, which effufed blood 
is apt to do, it will no doubt be better 
to amputate the limb than to make any 
attempt to fave it : But in fuch a cafe, it 
is not the aneurifm for which amputa- 
tion is advifed, but a morbid ftate of the 
parts, induced by the difeafe being al- 
lowed to continue too long before any 
effectual meafure is adopted for its re- 
moval. In the commencement, and for 



326 Of Caufes that render Ch.XLtlf; 

a confiderable time thereafter, of the 
femoral or poplitean aneurifm, I mould 
never advife the amputation of a limb : 
for different instances are on record of 
limbs being faved by the operation for 
the aneurifm, even where the artery was 
injured in the fuperior part of the thigh r 
But where fuch an extenlive cedematous 
fwelling is induced all over the under 
part of the limb, as to leave no room to 
hope that it could again be reftored to 
ufe, even allowing the operation for the 
aneurifm to fucceed, it will no doubt be 
better to amputate immediately than to 
attempt the operation. 

The aneurifm we here allude to, is that 
which proceeds from a dilatation of the 
artery, and in which the coats of the 
veffel have burfl, fo as to produce a con- 
fiderable efljmon of blood into the fur- 
rounding cellular fubftance, probably be- 
fore any proper amftance is defired. 
This will feldom happen but with the 
pooreft clafs of people ; and therefore 
this difeafe, in the flate we are now 

fpeaking 



Se<ffc. II. Amputation necejfary. 32J 

fpeaking of, is chiefly found in hofpitals. 
At firft it is always attended with a good 
deal of pulfation ; but in its 'later ftagea 
the fwelling becomes fo large that the 
beating of the artery is fcarcely, if at all, 
difcovered ; by which it is apt. to be mis- 
taken for a tumor of a different kind : 
But for the moft part, a due attention to 
the hiftory of the cafe from the begin- 
ning, will lead to a knowledge of its 
real nature. 

The 10th and laft general caufe we 
enumerated, by which amputation may 
become neceifary, is particular diftor- 
tions of a limb. 

Where a limb is in other refpects per- 
fectly found, it will feldom happen that 
any diftortion to which it is liable will 
be confidered as a fufficient reafon for 
this operation : But in the courfe of 
much bufinefs, cafes are fometimes met 
with in which limbs are fo much diftort- 
ed, and are productive of fo much di- 
ftrefs, that patients rather incline to have 

them removed than fubmit longer to the 

in- 



328 Of 'Caufes that render Ch.XLIII; 

inconvenience. When in fuch circum- 
ftances we are not able to remove the 
diftortion by means of a. more gentle na- 
ture, we are under the neceflky of com- 
plying with the patient's requeft* 

Thefe are the feveral caufes by which 
the amputation of a limb may be render- 
ed necefTary. As they are very various^ 
and as the lofs of a member is to every 
patient an object of much importance^ 
they merit, in every inftance, the utmoft 
attention from practitioners. Indeed 
this point of practice, namely, that of 
fixing with precifion thofe cafes in which 
the amputation of limbs mould be advi- 
fed, with the molt fuitable periods in 
each, is attended with fiich difficulty, 
and a furgeon is fo apt to be blamed if 
he, proceeds to the operation fo long as 
the fmalieft doubt remains of the pro- 
priety of it, that it mould be held as a 
fixed regulation with every practitioner,- 
never to operate but with the advice of 
fome of his brethren in confutation, 

when 



Seel. II. Amputation necejary. 329 

when this can poflibly be obtained. We 
fhall now proceed to defcribe the method 
of operating. 



SECTION III; 



General Remarks on the Method of Ampuiath 
Limbsi 



SURGERY is not perhaps in any in- 
stance brought to greater perfection 
than in the method of amputating limbs. 
Before the invention of the tourniquet* 
this operation was attended with fo much 
hazard, that few furgeons ventured to 
perform it : Nay, long after the intro- 
duction of this inftrument, the danger 
attending it was fo great, that more than 
one half perilhed of all who had refolu- 
tion to fubmit to it. 

In the prefent improved ftate of the 
operation, I do not imagine that one 

Vol. VI, Y deat-J* 



330 Gentral Remarks Ch.XLIII. 

death will happen in twenty cafes ; even 
including the general run of hofpital 
practice : And in private practice, where 
due attention can be more certainly be- 
llowed upon the various circumftances 
of importance relating to the operation, 
the proportion of deaths will not be fo 
great. 

The circumftances in this operation 
which more particularly require atten- 
tion, are, the choice, when this is in our 
power, of the part at which a limb 
fhould be amputated ; the prevention of 
hemorrhagy during the operation ; the 
divifion of the fkin, mufcles, and bones, 
in fuch a manner as to ( admit of the 
flump being entirely covered with ikin ; 
the tying of the arteries alone, without 
including the nerve or any of the con- 
tiguous parts ; fecuring the teguments in 
a proper fituation, fo as to prevent them 
from retracting after the operation ; and • 
a proper fubfequent treatment of the 
cafe. . 

Next to fecuring the patient from lofs 

of 



Sect. IIL on Amputation, 331 

of blood, the mofl material of thefe is 
the faving fuch a proportion of the foft 
parts as will cover the flump, fo as to 
heal the fore as nearly as poffible by the 
firft intention : for without this, the 
wound produced by the removal of a 
large limb is always extenfive ; the cure 
accordingly proves tedious ; and in many 
cafes the difcharge proves fo copious, 
that the patient's health is irreparably 
hurt by it. The inconveniences arifing 
from this were fo obvious, that various 
attempts were made, from time to time, 
to improve this part of the operation. 
At firft, all that was done in amputating 
a limb, was cutting the foft parts down 
to the bone by one ftroke of a knife, and 
afterwards dividing the bone with a faw 
at the edge of the retracted mufcles. 
It was afterwards propofed by Mr Che- 
felden to divide the foft parts by a double 
incifion ; to divide the fkin and cellular 
fubftance with a circular incifion ; and 
then to cut through the mufcles at the 
edge of the retracted fkin : by this 
Y 2 means 



3j2 General Remarks Ch. XLIIL 

means tlis faw was applied higher in the 
bone, and the flump was better covered 
both with mufcles and fkin. Still, how- 
ever, an extenfive fore was left; info- 
much that in amputations of the thigh, 
a cure was feldom performed in lefs than 
three or four months ; often five or fix 
were required ; and after all, the flumps 
were commonly pyramidal, by the. bone 
projecting beyond the foft parts : It of- 
ten happened too, that another fore was 
produced by this part of the bone exfo- 
liating, long after the patient confidered 
himfelf as perfectly well. 

To prevent this Pyramidal or Sugar- 
loaf Stump, as it is termed, a bandage 
or circular roller was employed, with a 
view to fupport the mufcles and tegu- 
ments, and prevent their retracting ; and 
when properly applied from the upper 
part of the limb downwards, it in fome 
degree anfwered the purpofe, but never 
fo effectually as to prevent the cure from 
being tedious. In order to fhorten it 
farther, it was propofed by the late Mr 

Sharpe, 



Se<5l. III. , on Amputation, 2$5 

Sharpe, in his Treatife on this Operation, 
to draw the teguments near together by 
flitches or pieces of tape paffed through 
them, and tied acrofs the flump : But 
the pain and inconvenience attending 
this was fo great, that it never was ge- 
nerally praclifed ; and Mr Sharpe him- 
felf at lafl defifled from it. 

It was now thought impoffible to im- 
prove this method of operating, fo as to 
fhorten the cure, and in place of a pyra- 
midal, to give the flump a plain furface. 
In confequence of this, about twenty 
years ago, different furgeons attempted 
to revive the flap operation ; which had 
been firfl practifed, upwards of a hun- 
dred years ago, by an Englifh furgeon of 
the name of Loudham. It was effected 
by faving a flap of the mufcles and fkin, 
in the manner we fhall afterwards de- 
fcribe, laying it over the flump, and fe- 
curing it in this fituation by proper ban- 
dages till it united to the parts beneath. 

As this afforded a thick mufcular cu- 
shion to the flump as well as a complete 
Y 3 co- 



334 General Remarks Ch.XLIII. 

covering of found fkin, the higheft ex- 
pectations were formed of it : but the 
objections to it, which we fhall after- 
wards mention, were fo great, that the 
utmofl exertions, even of expert furgeons, 
to render it more perfect, have not been 
able to introduce it to general ufe. 

This failure again excited the attention 
of practitioners to the improvement of 
the common operation of amputation ; 
and their endeavours have not proved 
unfuccefsful. By the prefent improved 
method of operating, fuch a quantity of 
teguments is faved as completely covers 
the (lump ; by which, in fome inftances, 
a cure is obtained by the firft intention 
without the formation of matter : And 
in all, unlefs there be fomething particu. 
larly bad in the habit of body, or unlefs 
the inflammation unexpectedly runs to a 
very unufual height, a cure is completed 
in the courfe of two or three weeks. As I 
confider the improvement by which thefe 
ads are effected as one of the moll im- 
portant in modern practice, I hope to be, 

ex- 



Sect. III. on Amputation. 33^ 

excufed, if I fhortly ftate the fhare I 
have had in the introduction of it, be- 
fore proceeding to defcribe the operation 
itfelf. 

In the courfe of my education, while 
attending the hofpital here, as well as the 
hofpitals of London and Paris, the in- 
conveniences arifing from the want of 
attention to the faving of Ikin in diffe- 
rent chirurgical operations, {truck me 
flrongly ; fo that I 'was refolved to take 
every proper opportunity in my own 
practice, of treating this point with par- 
ticular attention. 

From the year 1772, when I fettled in 
bufinefs, I laid it down as a maxim, not 
to be deviated from, to fave as much ikin 
and cellular fubflance in the removal of 
tumors, whether cancers or others, when 
the foundnefs of parts admitted of it, as 
would completely cover the fores ; and 
in amputating any of the extremities; to 
fave as much of them as would entirely 
cover the flumps. I firft performed am- 
putation in the courfe of that year ; and 
Y 4 finding 



336 General Remarks Gh.XLIlL 

finding the improvement of faving fkin 
%o anfwer even beyond my expectation, 
for- the cure of a large ftump in an am- 
putation of the thigh was completed in 
three weeks, I did not fail of putting it 
afterwards in practice both in public 
and private. The practice was Ukewife 
adopted by my friend Mr Hay, and more 
lately by fome other gentlemen in their 
attendance at the hofpital ; and ever fince 
that period, Mr Hay and I have invari- 
ably adhered to it, fome deviations being 
pccauonally introduced in the mode of 
doing it, with a view of rendering it 
more perfect ; by which the cures have 
in every inftance been greatly fhortened. 
In various cafes, large flumps, which by 
the ufual method would have required 
fever al months, were cured in as many 
weeks : In a few, as was obferved above, 
the parts united by the firft intention : 
and in all, a plain uniform ftump was 
produced. 

After this had been practifed for feve- 
ral years, Mr Alanfon of Liverpool, in 



Scdl. III. on Amputation. 237 

the year 1779, published fome Obferva- 
tions upon Amputation, in which a me- 
thod of operating is defcribed, which af- 
ter nine years experience, he recommends 
in the warmed manner, as anfwering 
every object to be expected from this 
operation; and more efpecially, that of 
curing the (lumps in a great meafure by 
the firft intention. 

As Mr Alanfon's mode of operating 
has of late been very defervedly preferred 
to every other that was before publifhed, 
I fhall afterwards give an account of it ; 
but in the mean time, I fhall defcribe 
that which I have long been accuftomed 
to practife, and which after various trials 
of every other of which I have yet heard, 
I dill continue to prefer. In the firft 
place, we (hall defcribe the operation as 
it is performed upon the thigh, and Oiall 
afterwards fpeak of the method of ampu- 
tating in other parts of the extremities. 



SEC- 



5<3 S Of Amputating Ch. XLIII. 

SECTION IV. 

Of Amputating the Tbigb. 



IN amputating either the thigh or leg, 
the patient fhould be placed upon a 
table of an ordinary height, with the leg 
properly fecured and fupported by an 
afliftant fitting before him. The other 
leg fhould likewife be fupported, at the 
fame time that the arms fhould be fecured 
by an affiflant on each fide, to prevent 
interruptions during the operation. 

The flow of blood to the limb fhould 
mow be flopped by the application of the 
tourniquet, in the manner we have men- 
tioned in the firft volume of this Work ; 
and as it is a matter of importance to 
have the inflrument placed as near as 
pofhbje to the top of the thigh, the cu- 

fhion 



PLATE LXXXIV. 



ITIG-J 




Setf. IV. the Thigh. 339 

ihion placed upon the femoral artery 
fhould reach the groin. 

This becomes abfolutely necefTary when 
the operation is to be performed on the 
upper part of the limb : But it may like- 
wife be done with fafety where it is to 
be taken off immediately above, the joint 
of the knee : And we may jufl obferve, 
with refpec~t to the moft proper place at 
which a thigh mould be amputated, that 
no more of it mould be taken away than 
is rendered necefTary by the difeafe ; for 
the more of it that is left, the more ufe- 
ful it proves. 

An afTiflant fhould now be directed to 
grafp the upper part of the limb with 
both hands, and to draw up the fkin and 
cellular fubflance as far as pomble : 
While they are in this ftate of tenfion, 
the operator, flanding on the outfide of 
the patient, fhould divide them with a 
circular incifion down to the mufcles : 
This may in general be done with one 
flroke of the amputating knife, fig. 3, 
Plate LXXXV. ; but in large limbs it is 

eafier 



34-0 Of Amputating Ch. XLIII, 

eafier done at twice. The affiftant con- 
tinuing to draw the teguments up- 
wards, the cellular fubftance connecting 
them to the mufcles beneath, mould 
be divided with the edge of the knife till 
as much of the fkin is feparated as the 
operator thinks will cover the flump com- 
pletely. 

The fkin being flill drawn tightly up- 
wards, the mufcles mould be divided clofe 
to the edge of it down to the bone by one 
perpendicular ftroke of the knife, begin- 
ning with the upper part of the large 
mufcles on the infide of the thigh, and 
continuing the incifion round through 
thofe beneath, and on the outfide till it 
terminates where it commenced. During 
this part of the operation, fome attention 
is neceffary to avoid the edge of the re- 
tracted fkin : but it may always be done 
if the operator be upon his guard, for he 
may with little difficulty have his eye 
upon the courfe of the knife from firft 
to laft ; nor can this part of the operation 
be done with fafety in any other manner : 

Evep 



PL ati-; i-x/XN 




Sea. IV. the Thigh. 341 

Even where different affiflants are em- 
ployed to protect the fkin, it will be apt 
to be wounded, if the operator does not 
follow the knife with his eye. 

In the ufual method of operating, the 
bone would now be fawn acrofs at the 
edge of the retracted mufcles : but we 
are more certain of having a good flump, 
if the mufcles be previoufly feparated 
from the bone for the fpace of an inch ; 
and it is eafily done by inferring the 
point of the common amputating knife 
between them, and carrying it freely 
round from one fide of the limb to the 
other. This being done, the mufcles and 
teguments muft be drawn up as far as 
the mufcles have been feparated from the 
bone ; and it is eafily done, either with a 
bit of flit leather, fuch as is reprefented in 
Plate LXXXIV. fig. 4. or with the iron re- 
tractors in the fame Plate, fig. 2. and 3. 
The periofteum fhould now be divided at 
the place where the faw is to be applied, 
and it fhould be done with one turn of the 
knife j for where much of it is fcrapcd off, 

very 



342 Of Amputating Ch. XLIlt, 

very tedious and troublefome exfolia- 
tions are apt to enfue : The knife fhould 
therefore be carried round the bone di- 
rectly beneath the retractors. At tins 
place the faw fhould be applied, and 
with long fteady ftrokes the bone fhould 
be divided. The faw reprefented in 
Plate LXXXV. fig. i. anfwers much 
better than the ufual form of the in- 
ftrument with a heavy iron back. In 
performing this part of the operation, 
the afiiftant holding the leg fhould be 
directed to fupport it with much equa- 
lity ; for if it be raifed too far, the mo-» 
tion of the faw will be impeded, while 
the bone will be apt to be fplintered if 
it be not fufficiently raifed. Any points 
or fplinters which may be left, fhould be 
immediately removed with the nippers,- 
Plate LVI. fig. 2. 

The retractors mould now be taken off; 
and the trunk of the femoral artery being 
drawn out with the tenaculum, a fufficient 
ligature fliould be made upon it before the 

tour* 



I 



Sea. IV. the thigh, 343 

tourniquet is loofened : But as the muf- 
cular branches of this artery cannot be 
difcovered as long as any compreflion re- 
mains upon them, the fcrew fhould be 
immediately untwifled fo far as to re- 
move it intirely. All the clotted blood 
fhould be now removed from the flump 
with a foft fponge foaked in warm water ; 
and every artery that can be difcovered 
fhould be fecured with a ligature, care 
being taken to leave the ends of the 
threads of a fufficient length to hang out 
without the 'lips of the wound. 

The blood- vefTels being all fecured, and 
the furface of the wound cleared of blood, 
the mufcles and teguments mould be drawn 
down till the fkin completely covers 
the flump ; and fhould be retained in 
this fituation by an affiftant till a flannel 
or cotton roller, previoufly fixed round 
the body to prevent it from flipping 
down, be applied in fuch a manner as to 
fupport and fix them : for which purpofe 
it fhould be pafled two or three times, 
nearly in a circular direction, round the 

top 



J44 Of Amputating Ch. XLIlL 

top of the thigh ; and fhould afterwards, 
with fpiral turns, be brought down near 
to the end of the (lump, of fuch a tight- 
nefs as to prevent the mufcles and fkin 
from retracing, without comprefling 
them fo much as to prove painful, or to 
impede the circulation. Here the roller 
mould be fixed with a common pin, 
while as much of it is left as will pafs 
two or three times round the flump, 
for a purpofe to be afterwards mention- 
ed. 

The ends of the divided mufcles being 
placed with as much equality as pomble 
over the bone, the edges of the fkin mult 
be laid exactly together, fo as to form a 
ftraight longitudinal line along the cen- 
tre of the flump. When there are only 
one or two ligatures, they fhould be left 
out' at the inferior angle of the wound ; 
but when there are feveral, they mould 
be divided between the two angles, to 
prevent the parts from fmTering by a 
large extraneous body fixed at any one 
place. 

While 



Sect. IV. the "thigh. 345 

While an afliflant retains the edges of 
the divided fkin in exact contact, two or 
three flips of adhefive plafler fhould be 
laid acrofs the face of the flump, to 
preferve them, nearly in this fituation ; 
and the whole furface of the flump 
mould now be covered with a large 
pledgit of foft lint ipread with Gou- 
lard's cerate, or the common calamine 
cerate of the Difpenfatories : Over this 
there fhould be placed a foft cufhion 
of fine tow with a comprefs of old li- 
nen. For the purpofe of retaining them, 
as well as with the view of making a 
gentle prefTure upon the flump, a flip 
of linen, of three inches in breadth^ 
mould be laid over them ; and fhould 
run directly acrofs, and not from above 
downwards. On being properly pla- 
ced, the remaining part of the roller 
fhould be employed to fix it, by paf- 
fing it two or three times round the 
flump ; and the prefTure formed by the 
crofs flrap may afterwards be increafed 
or diminifhed at pleafure, by drawing 

Vol, VI. Z * 



&6 Of Amputating Cfr.XLHE 

it with more or lefs tightnefs, and 
fixing it with pins to the circular rol- 
ler. 

While we apply the roller, the tourni- 
quet Ihould be removed, and replaced 
immediately when the flump is drefTed- 
If left loofe it gives no uneafinefs ; and 
it enables the attendants to check any 
hemorrhagy which may happen : a cir- 
cumflance which merits attention for 
feveral days after amputation of any of 
the extremities. 

The patient mould now be carried to 
bed ; but inftead of raifing the ftump to 
a confiderable height with pillows, as is 
ufually done, it fhould be laid fomewhat 
lower than the reft of the body : for this 
purpofe, the bed mould be made with a 
gentle declivity from above downwards, 
and nothing fhouki be put beneath the 
flump but a little fine tow. 

To prevent the patient from moving 
the' limb inadvertently, as well as to 
guard in fome meafure againft the ef- 
fect of thofe ipafms which often prove 

trouble* 



I 



Sett. IV. the Thigh. J47 

troublefome after this operation, I com- 
mpnly employ two flips of linen or flan- 
nel to fix the flump down to the bed. 
It is eafily done, by laying one acrofs 
near the extremity of the flump, and an- 
other near to the root of the thigh. 
They fhould be pinned to the circular 
roller round the limb ; and the ends of 
each of them fhould be pinned to the 
bed : or they may be tied to it by pieces 
of fmall tape previoufly fewed to the 
bed or to the matrefs ; which anfwers 
better than a feather bed for any patient 
that is to be long confined. A bafket 
or hooped frame fhould now be put 
over the flumps to protedl it from the 
bed-clothes ; and whether the patient 
complains much or not, I make it a con- 
flant rule to give him an anodyne, by 
which he remains quiet and perfectly 
eafy through the remainder of the day,, 
inflead of being refllefs and diftrefled, 
which he is otherwife apt to be. 

As hemorrhages will fometimes hap- 
pen, even many hours after the opera-* 
% 2 tion* 



348 Of Amputating Ch.XLTIt 

tion, the attendant who take* the charge 
of the patient fhould be flrictly enjoined 
to examine the flump frequently with 
the utmoft care ; and' on any quantity 
of blood breaking out, to twift the tour- 
niquet fufficiently tight to put a flop to 
it, till amftance is procured. I think it 
right, however, to obferve, that in ge- 
neral it is the fault of the practitioner 
when this very perplexing occurrence 
takes place ; for it feldom happens when 
the arteries are fearched for in the time 
of the operation with that accuracy 
which the importance of the cafe re- 
quires. Indeed hemorrhages are lefs- 
frequent after this method of operating, 
than when the mufcles are left uncover- 
ed ; and this is one material advantage 
that remits from it : for however atten- 
tive a furgeon may be in fecuring the 
arteries, the irritation produced upon 
an extenfive wound, and the fpafms 
which enfue, very frequently terminate in 
fatal hemorrhages. Of this I have known 
feveral inflances j while no difcharge 

of 



Seel. IV. the Thigh. 349 

of any importance has ever happened 
in the method of operating we are now 
defcribing. I believe too, as I have elfe- 
where remarked, that fome additional 
fecurity is derived from the ufe of the 
tenaculum : for although thofe who have 
not been in the habit of ufing it, are apt to 
confider it as more uncertain than the 
needle, yet it is far from being fo. I 
will not fay that hemorrhagies will never 
cnfue where the tenaculum is employed .; 
"but it has fo happened in the courfe of 
my obfervation, that the needle was ufed 
in every cafe of hemorrhagy that proved 
fatal. 

Where there is only a trivial oozing 
of blood we need not be alarmed ; nor 
will it be necefTary to remove the dref- 
lings : But whenever the difcharge is fo 
confiderable as to give caufe to fufpect 
that it proceeds from a large artery, no- 
thing but the fecuring it with a ligature 
can be dedended on. This being done, 
the dreflings muft be renewed in the 
fame manner as at firft. 

Z 3 The 



55© Of Amputating Ch.XL.III. 

The only other fymptoms we have rea- 
fon to dread, during the firft three or 
four days after the operation, are thofe 
fpafmodic affections of the mufcles which 
we have alluded to above, and the in- 
flammation and tenfion of the flump, 
with the confequent fever which in fome 
degree fucceed to every cafe of amputa- 
tion, but which always prove hazardous 
when they proceed to any great height. 

When the arteries are tied without in- 
cluding the nerves, or any part of the 
contiguous mufcles, thefe fpafms feldom 
become troublefome : But when they do 
take place, if laying the limb in as eafy 
a relaxed ftate as poflible does not ren- 
der them moderate, we muft truft tq 
opiates for their removal. 

For the prevention of inflammation, 
the patient muft be confined to as low a 
regimen as the ftate of his firength will 
permit. In weak emaciated habits this 
rnuft be managed with much difcretion, 
as the constitution might be materially 
jiiurt by too low a jdiet : but where there 

i§ 



tJedt.IV. the Thigh. 3£i 

is much plethora, with a tenfe fibre, to- 
gether with a ftrict antiphlogiflic regi- 
men, the patient mould be blooded as 
foon as quicknefs and fulnefs of pulfe or 
other fymptoms of fever take place : he 
fholild take plentifully of diluent drink ; 
and his bowels mould be kept open with 
any of the cooling neutral falts. 

It is proper, however, to obferve, that 
it is during the firft days only after the 
operation that remedies of this kind are 
in general neceflary. When the inflam- 
matory ftage is over, evacuations of 
every kind are to be dreaded ; even laxa- 
tives are apt to do mifchief if they are 
ever carried farther than is jufl nece£- 
fary for preferving a regular Hate of the 
bowels. 

At the end of the third day, whatever 
the previous fymptoms may have been, 
the flump fhould be examined. Where 
a free fuppuration is expected, as always 
happens when the flump is not covered 
with fkin, the parts mould not be looked 
at till the fourth or fifth day : but here 
Z 4 there 



35$ Of Amputating Ch. XLIIT. 

there is no reafon for this delay ; and 
the patient is always rendered more eafy 
and comfortable by the removal of the 
firft draftings. For this purpofe the flump 
mould be gently fupported by an aflifl- 
ant, till the laft turns of the roller are 
undone, and till the crofs flips, tow, and 
even the large pledgit of ointment next 
the fore are removed. In a few cafes 
the parts will be found to be united by 
the firft intention ; but for the moll part 
it will be otherwife : There will be a 
fmall quantity of matter over the furface 
of the flump, chiefly at the inferior 
angle of the wound ; and the parts will 
be red, tenfe, and painful to the touch, 
with a fmall feparation or opening be- 
tween the edges of the divided fkin, 
notwithflanding the p] afters employ- 
ed to retain them. As in this ftate the 
plafters will do no fervice, they fhould 
likewife be removed ; and it is eafily 
done when they are thus moiftened with 
matter. The furface of the flump 
Should now be covered with a pledgit of 

the 



Se&. IV. the Thigh. 353 

the fame ointment as at firft ; and a 
cufhion of foft tow being laid over it, the 
crofs flips of linen and circular roller 
fhould be again employed ; but with no 
more prefTure than is merely necelTary 
for fupporting them. 

In this manner the dreflings mould 
be renewed every fecond day; when, by 
the feventh or eighth day, the inflamma- 
tion and tenfion will in general be fo far 
diminifhed as ( to admit of the ligatures 
on the arteries being eafily removed j at 
leaft they may now be gently pulled 
daily, and for the moft part they will 
yield on the fecond or third trial : when 
allowed to remain longer, they not only 
prevent the wound from healing, but are 
apt to be more difficult to remove after- 
wards. 

As long as the roller is preferved clean, 
it may be allowed to^remain ; but as foon 
as it becomes fullied with matter, it 
mould be removed and another applied 
in its place ; nor fhould it be entirely 
laid afide till the third or fourth week 

from 



'354 Of Amputating Ch. XLIfl, 

from the operation. After this period, 
however, it mould be removed, as when 
longer continued it is apt to render the 
limb fmaller than the other. 

As foon as the fore is obferved to be 
perfectly clean, with granulations fprout- 
ing up in different parts of it, as the pain 
and tenfion will now be quite removed, 
we may with fafety venture to complete 
the cure, by drawing the edges of the 
wound together by adhefive plafters. In 
this ftate of the fore no harm ever en- 
fues from it, and it Shortens the cure 
considerably. 

By this management, even the largeft 
flumps will for the molt part be heal- 
ed in three or four weeks ; often in 
lefs. But it mufl be remarked, that 
although we may in general depend on 
this in private practice, where every 
circumftance that can conduce to the 
welfare of the patient will meet with 
attention, and where especially we may 
always obtain a well-ventilated apart- 
ment and proper diet 5 yet in public 

hofpitals ? 



Sea. IV. the Thigh. 355 

hofpitals, where thefe points cannot be 
duly attended to, and where the patient 
often fuffers more from the bad air which 
he breathes, than from the operation it- 
felf, the fuccefs attending it will not in 
every cafe be fo great. Inflead of the 
teguments adhering readily to the parts 
beneath, large quantities of matter fome- 
times form between them, which always 
renders the cure more tedious, and which 
in fome cafes cannot be accomplifhed 
but by fending the patient to a more free 
air, and by a more plentiful allowance 
of wine and other cordials than can in 
general be obtained in hofpitals. But 
for one inflance of this kind, in the ope- 
ration we have defcribed, I may with 
fafety affirm, that twenty will occur in 
the ufual mode of conducting it : In the 
former, thofe obftacles to a cure do not 
commonly occur ; in the latter, they arc 
often obferved. 

When fpeaking of the time in which 
{lumps may be expected to heal, I think 
it right to obferve, that it fliould not be 

our 



356 Of Amputating Ch. XLTIt, 

our object to accomplifh a cure in the 
ftrft inflance without the formation of 
matter : It commonly anfwers better when 
effected in the more gradual manner we 
have pointed out. When a flump heals 
fuddenly, and the edges of the divided 
fkin adhere by the firft intention, the te- 
guments are apt to be puckered and un- 
even, and the ligatures of the arteries 
are removed with difficulty. Of this I 
have had different cafes, when fuch flrong 
adhefive plaflers were made ufe of, as 
kept the edges of the fkin in clofe con- 
tact : But when the common court-plaf- 
ter is made ufe of, or any other compo- 
sition poffeffed of the fame degree of ad- 
hefive property, although the teguments 
will be prevented from feparating to any 
confiderable extent, yet they will readily 
yield to the retraction which ufually 
takes place on the acceffion of tenfion 
and pain. In this manner, a flight fepa- 
ration is ufually produced ; by means of 
which the ligatures are eafily taken out ; 
any matter that may form is readily dis- 
charged ; 



Setf. IV. the fhlgh. 357 

charged ; the corners left above and be- 
neath, by the teguments being drawn to- 
gether, are much lefTened ; and the flump 
is always left fmo'oth and equal : Hence 
thofe flumps which take three weeks or 
perhaps a month to heal, are ufually better 
than thofe which heal much fooner. The 
advantages attending a fpeedy cure, and 
the covering the flump with fkin, are fo 
great, that they need not be enumerated : 
but I thought it right to mention the in- 
conveniences which occur from our en- 
deavouring to haflen the union of the 
divided fkin too quickly, either by ad- 
hefive plaflers, or futures, which lafl has 
in fome cafes been attempted. 

It will be readily perceived, that the 
principal difference between this opera- 
tion and the ufual method of amputa- 
ting, confifls in the faving of as much 
of the mufcular fubflance of the limb 
as will completely cover the bone, to- 
gether with as much fkin as will cover 
the whole furface of the flump : But it 
is proper to remark, that we may err in 

faving 



35 8 Of Amputating Ch.XLIll.' 

faving more of each of thefe parts than 
is requifite, and that fome attention is 
therefore neceflary to guard againft it. 
In leaving too much mufcular fubftance, 
we muft neceffarily fhorten the limb too 
much, by fawing the bone higher than 
we otherwife would do ; and by faving 
too much fkin, we render the furface of 
the fturap puckered and uneven. 

With refpec"l to the quantity of muf- 
cular fubftance that Ihould be faved, I 
have hitherto found, that the directions 
given above, in general, anfwer the pur- 
pofe. By feparating the mufcles from 
the bone for the fpace of an inch, and 
fawing it at this height, above where it 
is divided in the ordinary method of am- 
putating, the bone will always be fufH- 
ciently covered with fleih ; and a very 
little experience enables us to judge of 
the quantity of fkin that fhould be faved 
for covering the flump : But even when 
more is faved than is altogether neceffary 
for this purpofe, a little attention will 
enable us to prevent inequalities. By 

an 



Sect. IV. the TbigB. 359 

an afliftant drawing down the teguments, 1 
in the manner we have directed, before 
the roller is applied, as much of them 
may be pulled down as is juft necefTary ; 
and if they are preferved in this fituation 
till the application of the roller is finifli- 
ed, any inconveniency which might have 
occurred from too great a quantity will 
be prevented. 

It will likewife be obferved, that in ma- 
king the firft incifion of the teguments, I 
have not defired a circular piece of tape 
to be made ufe of, as is ufually done, to 
ferve as a direction for the knife. This 
deviation from the common practice has 
been long adopted by fome individuals ; 
but fo far as I know, it was firft fuggeft- 
ed by the late Doctor Hunter of London ; 
and I think it a material improvement 
of this part of the operation : for befides 
the faving of time, which is always of 
importance in that ftate of anxiety to 
which a patient is reduced who is placed 
upon a table for the purpofe of lofing a 
limb, it in reality puts it in our power 

to 



360 Of Amputating CK. XLIII* 

to make tlie incifion with more neatnefs, 
more fpeedily, and with lefs embaraff- 
ment, than when the tape is employed. 
Thofe who have been accuflomed to the 
tape will at firft be of a different opinion ; 
but whoever will lay it afide, will find, 
that the circular incifion may be made 
with more exactnefs merely by follow- 
ing the knife with the eye ; and I am cer- 
tain that it may be done in one half of the 
time. When the tape is employed, a good 
deal of time is loft in endeavouring to 
keep the knife exactly in a line with it ; 
and if it be not applied with the utmoft 
exactaefs, it necefTarily renders the in- 
cifion ragged and unequal ; an occurrence 
I have obferved in different inftances, 
even with expert furgeons, while I never 
perceived any inequality where the tape 
was not ufed. 

It has been objected to the operation 
now defcribed, that being more tedious 
than the ufual method of amputating, it 
mufl necefTarily create more pain. The 
difference in this refpedt, however, muft 

be 



Se<5l. IV. the fbigh. 361 

be trifliiig ; for it muft be remembered, that 
the incifion of the fkin, which is the molt 
painful part in every operation, is the fame 
in both. The divilion of the cellular fub- 
flance is quickly performed, and little or 
no pain enfues from it : And the third in- 
cifion, if we may fo term it, or the fepara- 
tion of the mufcles from the bone, may be 
performed in the tenth part of a minute. 
In different inftances I made ufe of a fcal- 
jpel for feparating the cellular fubftance 
from the mufcles beneath, as well as for 
feparating the mufcles from the bone ; 
but I now find that both thefe parts of 
the operation may be done with the com- 
mon amputating knife, with equal eafe 
and expedition : and we mould avoid 
multiplying inftruments, wherever the 
intention can be anfwered equally well 
with a fmaller number. The knife de- 
lineated in Plate LXXXV. fig. 3= is the 
one I now prefer, after trying various 
forms of it : It is of a middling fize, fome- 
what fhorter than the one in common 
life, and perfectly flraight. The curved 
Vol. VI. A a knife 



362 Of Amputating Ch. XLIIL 

knife is ftill ufed by fome practitioners, 
but I have never heard any good reafon 
given for it. 

If any furgeon fhould find it difficult to 
feparate the mufcles from the bone with 
this knife, the inftrument recommended 
by Mr Gooch, and delineated in Plate 
LXXXV. fig. 4. may be employed. 

I fhall now defcribe fuch parts of Mr 
Alanfon's method of performing this ope- 
ration as are peculiar to himfelf ; and in 
order to convey the meaning of the author 
with exadtnefs, I fhall give it in his own 
words, from the fecond and laft edition of 
his book, page fifty-firft. 

" Apply the tourniquet in the ufual 
way ; ftand on the outude of the thigh j 
and let an afliftant draw up the fkin and 
mufcles, by firmly grafping the limb cir- 
cularly with both hands. The operator 
then makes the circular incifion as quick- 
ly as pomble through the fkin and mem- 
brana adipofa down to the mufcles : He 
next feparates the cellular and membra- 
nous attachments with the edge of his 

knife,. 



Sed. IV. the "Thigh. 363 

knife, till as much fkin is drawn back as 
will afterwards, conjointly with the fol- 
lowing divifion of the mufcles, cover the 
furface of the wound with the moft per- 
fect eafe. 

'* The afliftant ftill firmly fupporting 
the parts as before, apply the edge of 
your knife upon the inner edge of the 
mufculus vaftus internus, and at one 
ftroke cut obliquely through the mufcles 
upwards as to the limb and down to the 
bone ; or, in other words, cut in fiich a 
direction as to lay the bone bare about 
two or three fingers breadth higher than 
is ufually done by the common perpendi- 
cular circular incifion : now draw the 
knife towards you, fo that its point may 
reft upon the bone, ftill attending to keep 
it in the fame oblique line, that the muf- 
cles may be divided all round the limb 
in that direction by a proper turn of the 
knife ; during which its point is kept in 
contact with, and revolves round, the 
bone. 

A a 2 " The 



364 Of Amputating Ch. XLI1L 

" The part where the bone is to be laid 
bare, whether two, three, or four fingers 
breadth higher than the edge of the re- 
tracted integuments ; or, in other words, 
the quantity of mufcular fubftance to be 
taken out in making the double incifion, 
muft be regulated by confidering the 
length of the limb, and the quantity of 
Ikin that has been previoufly faved by 
dividing the membranous attachments. 

" The quantity of fkin faved, and muf- 
cular fubftance taken out, muft be in 
fuch an exact proportion to each other, 
as that, by a removal of both, the whole 
furface of the wound will afterwards be 
eafily covered, and the length of the 
limb not more fhortened than is necefla- 
ry to obtain this end. However, it is to 
be obferved, that the more mufcular fub- 
ftance we fave, by fully giving the ob- 
lique direction to the knife, inftead of 
dividing the membranous attachments, 
the better." 

Mr Alanfon now gives fome directions 
for the ufe of the retrador ; for fecuring the 

divided 



Sea. IV. the Thigh. 365 

divided arteries with ligatures ; and for 
the application of the flannel roller. 
Afterwards he proceeds thus : — " You 
are now to place the fkin and mufcles 
over the bone in fuch a direction as 
that the wound fhall appear only in a 
line with the angles at each fide ; from 
which points the ligatures are to be 
left out, as their vicinity to either angle 
directs : The fkin is eafily fecured in 
this pofture by long flips of linen or lint, 
about two fingers in breadth, fpread 
with cerate or any other ointment : if 
the fkin do not eafily meet, it is belt 
brought into contact by flips of linen 
fpread with flicking plafler. Thefe are 
to be applied from below upwards acrofs 
the face of the flump, and over them a 
foft tow pledgit and comprefs of linen, 
the whole to be retained by the many-tail- 
ed bandage, with two tails or flips to 
come from below upwards, to retain the 
dreflings upon the face of the flump." 

Mr Alanfon ufes a knife with a double 
edge, which he thinks preferable to the 
one commonly employed. 

A a 3 As 



366 Of Amputating Ch. XLI1I. 

As I wifh the author's ideas to be clear- 
ly under flood, I think it right to add, that 
in page 1 7. he directs the bone to be laid 
bare three or four fingers breadth higher 
than is ufually done by the common per- 
pendicular incifion of the mufcles ; that 
is, that by the oblique direction of the 
knife, three or four ringers breadth of 
mufcular fubftance mould be fcooped 
out. And in page 21. he obferves, that 
" a (lump formed in the thigh, agreeably 
to the foregoing plan, if you bring the 
parts gently forwards after the opera- 
tion, and then view the furface of the 
wound, may in fome degree be faid to re- 
ferable a conical cavity, the apex of which 
is the* extremity of the bone ;" and the 
parts thus divided, he obferves, are obvi- 
pufly the beft calculated to prevent a fugar- 
loaf flump. 

From what has been faid, it will ap- 
pear, that Mr Alanfon's method of 0- 
perating differs chiefly from that which 
I have advifed above, in the manner of 

dividing 



Sea. IV. the Thigh. 367 

dividing the mufcles, and in the after 
pofition of the fkin. Every furgeon is apt 
to be partial to that mode of operating 
which he has been accuftomed to prac- 
tife ; but being always anxious to have this 
very important operation improved to the 
highefh pofTible degree, I was refolved to 
give Mr Alanfon's method a fair trial, 
being hopeful from the accounts received 
of it, that I mould find it anfwer better even 
than that which I have fpoke fo Highly of. 
I can with truth however aflert, that it 
did not anfwer my expectation. The 
flumps formed by it are indeed much 
better than can be made by the ufual 
method of amputating ; but the removal 
of fuch a large portion of mufcular fub- 
fiance, as is done by Mr Alanfon's ob- 
lique incifion, produces a hollow, which 
not only retains the matter, but which 
prevents the flump from being fo fmooth 
and equal as when the fkin is fupported 
by a flat mufcular furface in the maimer 
we have advifed. Mr Alanfon, who is 
jn the daily practice of it, may be able to 
A a 4 obvi^ 



368 Of Amputating Ch. XLIIL 

obviate thefe difficulties ; but I know 
that I cannot make fuch a good flump 
in this manner as I always do in the o- 
ther method of operating ; nor is Mr A- 
lanfon's own idea fo completely anfwered 
by his method of operating. He very 
properly obferves, page 63. that in the 
thigh we want a fufficient cufhiqn be- 
tween the bone and machine to be ufed 
in walking ; that the more mufcular 
fubftance that is faved, the farther will 
the point of bone on which the prefTure 
principally produces inconvenience, be 
removed from the furface of the ma- 
chine ; and likewife, that a more vigor- 
ous circulation will be kept up all round 
the extremity of the bone and flump, 
which leffens the danger of exfoliation. 
Now it is obvious, that the end of the bone 
will not be fo much covered with muf- 
cular fubftance when a considerable por- 
tion of the mufcles is removed by the 
oblique incifion as when they are allow- 
ed to remain ; nor will the circulation be 
fo vigorous round the end of the bone. 

But 



Sed. IV. the Thigb. 369 

But admitting Mr Alanfon's method 
of operating to be in every point equal 
to the other, the greater difficulty of 
performing it is a weighty objection to 
it. Indeed few, I believe, will be able 
to divide the mufcles by the oblique in- 
cifion without mangling the fkin, even 
with the explanation given by Mr Alan- 
fon in the laft edition of his book. Ac- 
cordingly we find, in page 204. that this 
actually happened in the hands of an ex- 
pert furgeon, Mr Lucas of Leeds, even 
where the divifion of the mufcles was 
not begun clofe under the retracted in- 
teguments, but a little lower. Nor will 
this be an uncommon occurrence, if the 
mufcles are divided with the edge of the 
knife, as is directed by Mr Alanfon. I 
have divided them with the point of the 
knife, but with difficulty ; for the point 
cannot be eafily carried round to the height 
of three or four fingers breadth above the 
retracted fkin, fo as to make a fmooth e- 
qual cut. I do not fee how the edge of the 
knife can be applied to cut fo obliquely up- 
wards 



370 Of Amputating Ch.XLIII. 

wards without hurting the fkin ; and yet 
Mr Alanfon's words are, " apply the edge 
of your knife, and at one ftroke cut ob- 
liquely thro' the mufcles, "&c. He defires 
indeed, that the incifion may be finifhed 
with the point ; but I do not under- 
fland how it can be done without cutting 
the fkin, if the point be not employed 
from firft to laft. Indeed Mr Alanfon 
himfelf admits that there is difficulty in 
this part of the operation ; for in page 
1 8. he fays, " that while one afliftant con- 
tinues a firm and fteady elevation of the 
parts, another mould attend to preferve 
the fkin from being wounded as the knife 
goes through the mufcles at the un- 
der part of the limb." This of itfelf ap- 
pears to be a material objection to this 
method of operating : For two affiflants, 
whole hands are all employed nearly at 
one point, muft be apt to embarrafs not 
only each other but the operator : And 
befides, it mufl often happen that two 
^iilftants cannot be procured. 

With 



Sed. IV. the Thigh. 371 

With refpect to the line of direction in 
which the wound mould be clofed, Mr 
Alanfon obferves, page 67, if it be form- 
ed from above downwards, the cicatrix 
will generally be found directly oppofite 
to the bone ; by which, in walking with 
an artificial leg, the point of preflure 
Hiuft be upon the new- formed fkin ; 
which he thinks will be avoided by 
forming the line in the contrary direc- 
tion from fide to fide : in which cafe, 
after the cure is complete, it will be 
found, that in confequence of the more 
powerful action of the flexor mufcles, 
the cicatrix is drawn downwards, and 
the extremity of the bone is therefore 
covered with the old fkin ; by which the 
greateft preflure falls upon this part, and 
not upon the new-formed fkin, 

I have not found, however, that this 
argument is of much importance ; for 
this retraction of the flexor mufcles 
which Mr Alanfon alludes to, is in a great 
meafure owing to the cuftom of eleva- 
ting the ftump after the operation, and 

may 



37* Of Amputating Ch. XLIII. 

, may be prevented by keeping it lower 
than the reft of the body, in the manner 
we have mentioned. And befides, the 
bone is fo well covered with mufcular 
fubftance, and the cicatrix is fo narrow 
when the operation is rightly done, that 
I have not met with a fingle inftance of 
any inconveniency arifing from this cir- 
cumftance mentioned by Mr Alanfon: 
whereas, the lodgement of matter proves 
always fo troublefome and pernicious, 
and would in all probability occur fo 
frequently, were the pradice generally 
adopted of making a tranfverfe opening 
inftead of a longitudinal one upon the 
face of the flump, that this appears to 
be a fufficient reafon for preferring the 
former. 

With a view to prevent that inequality 
on the furface of the flump, which arifes 
from the retradlion of the flexor mufcles 
of the thigh, I have in fome cafes divid- 
ed thefe mufcles an inch lower than thofe 
of the refl of the limb. After dividing 
the fkin and cellular fubflance with a 

cir- 



Se&. IV. the Thigh. 373 

circular incifion in the ufual way, this is 
eafily done ; and it prevents this incon- 
venience effectually : but it is not necef- 
fary when the flump is treated in the 
manner we have mentioned. 

Whether others may deem thefe ob- 
fervations upon Mr Alanfon's method of 
amputating important or not, I cannot 
determine ; but as they appeared to me 
to be of confequence, I thought it my 
duty to offer them. 

It is but juflice, however, to remark, 
that the public is much indebted to Mr 
Alanfon for his affiduity in endeavouring 
to improve this very important opera- 
tion, and for the many ufeful practical 
remarks contained in his publication. 



SEC- 



374 Of Amputating Ch. XLHL- 



SECTION V. 



Of Amputating the Leg. 



IN amputating the thigh we obferved, 
that as much of the limb mould be 
faved as can be done with propriety ; for 
the longer the flump the more utility is 
derived from it : But in the amputation 
of the leg, it has hitherto been almoft a 
general rule to take it off a little below 
the knee, even where the difeafe for 
which it is advifed is feated on or near 
the ancle, and where accordingly the 
operation might be performed much 
lower. The reafon given for this is, that 
a few inches of the leg being faved, an- 
fwers as a fuiKcient reft to the body in 
walking when the limb is infer ted into 
the box of a wooden leg ; and when much 
more of it is left, that it proves trouble- 

fome 



Sect. V. the Leg. 3 75 

fome both in walking and fitting, with- 
out being attended with any particular 
advantage. 

Were we to conclude, that the com- 
mon practice of bending the joint of the 
knee and refting upon the anterior part 
of the leg was necefTary, this method of 
operating a little below the knee would 
be admitted as the be ft : But as we have 
now had many inftances of patients 
walking equally well with machines fo 
contrived as to admit of the ufe of the 
knee-joint ; as thefe machines, by refem- 
bling the human leg, are much more 
pleafing to the eye than the wooden ones 
in common ufe ; and as the operation 
may be done with much more eafe and 
iafety to the patient a little above the 
ancle, I am of opinion that it mould al- 
ways be advifed to Ibe done here when- 
ever it is practicable, inftead of the ordi- 
nary place a little below the knee. 

The operation is eafier done a little a- 
bove the ancle than at the upper part of 
the leg, by the parts to be divided being 

lets 



376 Of Amputating Ch. XLIli 

lefs extenuve : for the diameter of the 
leg is here considerably lefs ; and it is 
done with more fafety by our being able 
to cover the bone more completely with 
foft parts, fo as to accompl'nh a cure in 
the fame manner and equally foon as in 
the thigh : Whereas, immediately below 
the knee, the bones are not only larger, 
but there is fuch a fcarcity of foft parts, 
that the cure proves always much more 
tedious, notwithftanding all our endea- 
vours to promote it ; infomuch, that in 
operating at the ufual place, about four 
inches beneath the patella, the fore, with 
all the attention we can give to it, will 
feldom heal, in lefs than ten or twelve 
weeks ; and in the common method of 
forming the double incifion, it will even 
require four or five months : Whereas, 
when the operation is rightly performed 
a few inches above the ancle, a cure may 
for the mod part be efFecled in a fort- 
night or three weeks. 

It is true that a method of amputating 
beneath the knee has been propofed, by 

what 



Sect. V. the Leg. 377 

what is termed the Flap Operation, and 
by which a cure may be more fpeedily 
effected than in the ufual way of opera- 
ting ; but ftill it is tedious, and at the 
fame time is liable to other objections, 
which we mall have prefently occafion 
to mention. I therefore conclude, that 
in every cafe that admits of it, amputa- 
ting a little above the ankle is pre- 
ferable to operating immediately below 
the knee. 

We are next to determine the moft 
proper place for the operation, when we 
are prevented by the extent of the dif- 
eafe in the leg from amputating lower 
than the ufual place beneath the knee. 
Where the upper part of the leg is found, 
it has hitherto been a fixed maxim to 
amputate below the joint of the knee 
rather than above it. 

While practitioners were unaquaint- 
ed with the prefent improvements in the 
operation of amputation, they feem to 
have adopted this maxim, chiefly from 
finding that the body retted more eafily 

Vol. VI. B b upon 



573 Of Amputating Ch. XLIIL 

ii;. on the , found fkin on the fore- part of 
the leg than on the Hump of the thigh : 
But now that the operation may be done 
above the knee, fo as that the fore will 
heal in lefs than one half of the time 
that is required when a leg is taken off 
immediately below the joint, and in 
fuch a manner that the flump is covered 
with found fkin, as well as with fome 
Enufcular fubflance, which admits of the 
patient refting upon it with freedom j 
this reafon, upon which the practice is 
chi f fly founded, falls to the ground. 

We have obferved above, that the cure 
of a (lump immediately below the knee 
is always tedious, owing to the great ex- 
tent of bone at this part, and the natural 
deficiency of foft parts. 

Upon the whole, therefore, I conclude, 
that amputation immediately below the 
knee mould feldom or never be advi- 
fed : But as no innovation will at firft 
be generally admitted, I think it right 
to deicribe the method of operating 

when 



Sea. V. the Leg. 37^ 

when it is determined to amputate at 
this part. 

The patient fhould be placed upon a 
table and fecured in the fame manner 
as in operating above the knee. The 
tourniquet ihould be applied a little 
above the knee, with the cufhion upon 
the artery in the ham. The foot and 
leg mould be fecured by an afliftant fit- 
ting before the patient, while the tegu- 
ments are drawn up by another afhflant 
towards the knee. The furgeon, {land- 
ing on the infide of the leg, Ihould now 
with the knife, Plate LXXXV. fig. 3. 
make a circular cut through the fldn and 
cellular fubftance down to the mufcles, 
fo far down upon the limb, that when 
as much of the teguments are feparated 
from the parts beneath as will cover the' 
flump, the mufcles and bones may bo 
divided immediately below where the 
flexor tendons of the leg are inferted. 
The interoffeous foft parts mud be di- 
vided either with the point of the ampu- 
tating knife or with the catline, Plate- 
B b 2 LXXXV, 



380 Of Amputating Ch. XLIIL 

LXXXV. fig. 2. The retradors, Plate 
LXXXIV. fig. 2. and 3. muft now be ap- 
plied fo as to fupport and protect the fkin 
and other foft parts from the faw employ- 
ed for dividing the bones. This being 
done, and the vefTels fecured, the tegu- 
ments fhould be drawn over the flump and 
retained with adhefive plafters, in the 
manner we have advifed in amputa- 
ting the thigh. The practice, indeed, 
fhould be the fame during the whole 
courfe of the cure ; only, in the appli- 
cation of the flannel roller, there is no 
necefli'ty for beginning at the top of the 
thigh : It fhould receive, however, two 
or three turns above the knee, to prevent 
it from flipping down. 

In feparating the adhefions of the fkin 
from the parts beneath, as much of the 
cellular fubfiance fhould be taken along 
with it as can be got ; otherwife the cir- 
culation in the fkin itfelf is apt to be- 
come fo languid as to prevent it from 
adhering to the parts on which it is ap- 
plied. It will be found too, that more 
attention is neceflary to deftroy the at- 
tach- 



Sed. V. the Leg. 381 

tachments of the fkin in this fituation, 
particularly on the fore part of the leg, 
than on the thigh, owing to the cellular 
fubftance being more condenfed where 
it lies fo contiguous to the bone, than in 
the thigh, where the mufcles intervene. 
And as this ftate of the cellular mem- 
brane prevents .the teguments from re- 
tracting freely after they are divided ; 
and as they cannot even be pulled fuf- 
nciently up by the affiftant, it is necef- 
fary to fold fuch of them as are fepara- 
ted from the parts beneath back upon 
the found fkin, before the divifion of 
the mufcles be attempted ; otherwife 
the fkin will either be cut with the knife, 
or the mufcles will not be divided fo 
high as is necelTary. 

Always at this part of the leg, and in 
a few cafes immediately above the ankle, 
I have found it neceffary to fold the Ikin 
back in this manner ; but hitherto no 
inftance has occurred in the thigh, but 
where the operation might have been 
done merely by pulling the teguments 
B b 3 . up, 



382 Of Amputating Ch.XLIII. 

up, in the manner we have formerly men- 
tioned. 

We have defired above, that in this 
operation the furgeon fhould ftand on 
the infide of the leg : By this means, 
if the knee and foot be turned inwards, 
fb as to raife the fibula, the faw may be 
applied in fuch a manner to both bones 
as to divide them nearly together ; which 
is the fureft method of preventing them 
from breaking when they are nearly 
fawn through : Whereas, on {landing on 
the outride of the patient, the fibula will 
be more apt to be left to the lad ; at the 
fame time that the law will be applied 
upon the ridge of the tibia fo as to act 
upon its longer! diameter, by which it 
will not be fo quickly divided. 

In operating above the ankle, that fpot 
fliould be fixed upon which will leave the 
flump of the mod convenient length for 
being fitted with a leather machine re- 
fembling the other leg. And I find from 
qbfervation, as. well as from the in- 
formation of Mr Wilfon, an ingenious. . 

tradefmai} 



Sea. V. the Leg. 383 

tradefman of this place, that nine inches 
from the joint of the knee is the beft 
length for this purpofe ; for it affords a 
fufEcient fupport to the machine, and at 
the fame time prevents it from being 
fo heavy and clumfy as when the leg is 
left of a greater length : for when taken 
off immediately above the ankle, the 
flump rauft go down to the very bottom 
©f the machine, which muft therefore be 
made thicker and heavier at the ankle 
than would otherwife be required ; at 
the fame time that it will prevent it from 
correfponding fo exactly as it otherwife 
would do to the fize of the other leg. 

In addition to what we have faid upon 
the method of amputating the leg imme- 
diately below the knee, we may obferve, 
that in operating above the ankle, it 
ihould be done exactly as we have ad- 
vifed in defcribing the amputation of 
the Thigh : Only in this fituation, inftead 
of mufcles, we find a portion of both 
bones covered merely with fkin and 
cellular fubftance ; but as the cellular 
B b 4 mem- 



384 9/ Amputating Gh,XMI. 

membrane is here commonly fufficiently 
lax, and in greater quantity than in the 
upper part of the leg, it is not only more 
eafily feparated from the periofteum, but 
ferves to give the bones a more complete 
covering : By which, when the operation 
is properly done, the cure for the mod 
part is accomplifhed in lefs than three 
weeks, and the furface of the ftump is 
equal and every where covered with 
found fkin. 



SECTION VI. 



Of Amputating with a Flap. 



IN performing the operation of ampu- 
tation in the ufual way, the cures were 
fo extremely tedious ; the health of the 
patients was thereby fo much injured ; 
and the flumps, when healed, were fo 
pyramidal, and fo thinly covered with 
1 < " '' '' foft 



Sea. VI. with a Flap. %%$ 

foft parts, that another method of ope- 
rating, as we have obferved above, was 
propofed upwards of a hundred years 
ago ; in which an attempt was made to 
obviate thefe difficulties, by preferving a 
flap of mufcles and fkin for the purpofe 
of covering the flump. 

This was fir ft propofed by one' Loud- 
ham, a Britifh furgeon : It was afterwards 
pra6lifed in Holland, Germany, Swit- 
zerland, and France ; and more lately 
by fome individuals in Britain and Ire- 
land : but it has never been received in- 
to general ufe, nor is it probable that it 
will ever be frequently performed. 

The chief objections to it were, the 
difficulty of reftraining the hemorrhagy 
when it happened to recur after the flap 
was applied and fixed in its fituation by 
futures ; for in order to difcover the 
bleeding arteries, it was neceflary to 
undo the whole ; the flap not adhering 
uniformly over the whole furface of the 
flump ; and the pain, inflammation, and 
tenfion, which fupervened, being much 

more 



386 Of Amputating Ch.XLIII. 

more fevere than after the ufual method 
of operating. 

To remove thefe difficulties, it was 
propofed, about twenty years ago, by Mr 
O'Halloran, an ingenious furgeon of 
Limeric, to drefs the flump and flap as 
feparate fores for the firfl twelve days ; 
when the rifk of hemorrhagy being over, 
the fymptoms of pain, inflammation, and 
tenfion, fubfided, .and fuppuration efta- 
blifhed, we are directed to turn the flap 
back upon the furface of the ftump, and 
by means of plaflers, compreffion, and 
bandage, to fecure it in this fituation till 
they unite together. 

By this improvement the operation 
was rendered more fafe and certain : and 
it is probable that it would gradually 
have come into general practice, if the 
improved method of operating, which 
we have already defcribed, had not in 
the mean time been introduced : But 
although this method will probably con- 
tinue to be generally preferred, yet in 
particular fituations, the operation with 

the 



Sea. VI. with a Flap. 387 

the flap may with much propriety be 
employed. Wherever the divided parts 
cannot be properly covered with fkin in 
any other manner, it ought certainly to 
be done with a flap : and this will always 
be the cafe in amputating the arm at the 
fhoulder, and the thigh at the hip-joint, 
as well as in removing any of the fingers 
or toes : It may likewife by fome be pre- 
ferred to the method of ©Derating which 
we have defcribed, when it is refolved 
to amputate immediately below the knee ; 
for the teguments being in this part ex- 
tremely thin, fome will be apt to imagine 
that the flump cannot in any other man- 
ner be fufficiently covered. But for the 
reafons we have already mentioned, it 
can never be neceflary, either above the 
knee ; in operating above the ankle ; nor 
in the arm or fore- arm. Some, however, 
may continue to prefer it, even in thefe 
parts : fo that it will be proper to defcribe 
the method of doing it in all of them. 
This we fhall attempt in the following 
Sections. 

SEC- 



388 Of Amputating at CLXLIII. 

SECTION VII. 
Of Amputating the Thigh at the Hip. Joint, 



THE amputation of the thigh at the 
hip-joint has always been confidered 
as one of the mofl hazardous operations, 
and therefore we have very few inftan- 
ces of its being performed. Indeed fur- 
geons in general have fpoke of it as one 
of thofe operations which authors might 
defcribe, but which would never be prac- 
tifed : And when we confider the great 
fize of the blood-velTels which fupply 
thefe parts ; the difficulty of command- 
ing the hemorrhagy during the opera- 
tion ; and the very extenfive wound 
which, in the ufual method of operating, 
mud necefTarily have enfued here ; we 
will not be furprifed at the averfion which 
has generally prevailed againft it. 

But 



Sea. VII. the Hip-Joint. 389 

But if thefe difficulties can be remo- 
ved ; if danger from hemorrhagy can be 
prevented during the operation, as well 
as afterwards ; if the fore can be fo 
completely covered with fkin as to be 
healed in the courfe of a few weeks ; 
and if cafes ever occur which would 
otherwife end in the death of the pati- 
ent ; we furely would not hefitate in ad- 
vifing it. Now, we hope to make it ap- 
pear, that the operation may be done 
with very little lofs of blood ; and that 
as much fkin may be faved as will cover 
the fore entirely : and no practitioner 
will doubt of difeafes taking place at the 
top of the thigh, which cannot be remo- 
ved but by amputating the limb. 

Having already treated fully of the 
caufes by which amputation of limbs may 
be rendered neceffary, we mail now refer 
to what was faid upon that part of the 
fubject ; and at prefent fhall only ob- 
ferve, that gun-lhot wounds, accom- 
panied with fractures of this part or. 
the bone, fpina ventofa, or caries of 
the head of the femur, will be the 

mod 



39° Of Amputating at Ch. XLIIL 

moft frequent caufes of amputating 
at the joint of the hip. When the ope- 
ration is refolved upon, it may be per- 
formed in the following manner. 

The patient fhould be placed upon a 
table ; and it will be found that the parts 
that are meant to be divided will be 
brought moft clearly into view by laying 
him on the found fide. In this fituatibn 
he fhould be fecured by two or three af- 
firmants, while another aihftant takes the 
management of the limb. 

Let a fmall pad or cufhion be now 
placed upon the femoral artery, imme- 
diately after it pafTes out from beneath 
Poupart's ligament into the thigh ; and, 
by means of a tourniquet applied as near 
as- poflible to the top of the limb, let 
the circulation 'be completely flopped. 
Let the fkin, membrana adipofa, and 
tendinous fafcia of the thigh, be divided 
by a circular incifion fix inches from 
the top of the thigh ; that is, at leaft 
three inches beneath the circular band 
of the tourniquet. Let the retracted 
fkin be- pulled an inch upwards ; and at 

' the 



Sect. VII. the Hip- Joint. 391 

the edge of it let the amputating-knife 
be applied, fo as with one perpendicular 
circular ftroke the mufcles may be cut 
down to the bone. If the mufcles be 
freely divided, they will retract fo much 
as to admit of fufhcient fpace for fecu- 
ring not only the femoral artery but all 
the mufcular branches. This being 
done, take a ftrong round-edged fcalpel, 
larger than the common fize, and com- 
mencing at the upper edge of the circular 
cut on the pofterior part of the thigh, 
make a deep incifion down to the bone, 
and carry it up of the fame depth to a 
little above the great trochanter into the 
joint. Let a fimilar cut be made on the 
oppofite fide of the limb, at a fufficient 
diftance from the femoral artery, and 
completely down to the bone. Let the 
two portions of flefh be now difTected from 
the bone, and the flaps formed by them 
be taken care of by affiftants, while any 
artery that may be cut mould be tied as 
foon as it is obferved. The joint be- 
ing laid bare, fome dexterity will be re- 
quired 



3g2 Of Amputating at Ch.XLIIL' 

quired to difengage the head of the 
femur from the acetabulum ; for it is* 
rendered difficult from being tied down 
to it by the ligamentum rotundum : But 
by turning the bone in different direc- 
tions, and particularly by preffing it in- 
wards, where it yields mod readily from 
the brim of the acetabulum being low- 
eft, the head of it will be fo far turned 
out of the focket on the oppofite fide as 
to admit of the ligament being reached 
with the point of a fcalpel or a firm 
probe- pointed bifloury ; but to accom- 
plifli this, the mufcles mud all be pre- 
vioufly detached from the bone; 

The head of the bone being taken out 
and the limb removed, we may examine 
the ftate of the acetabulum : for if it be 
found, our profpect of a cure will be 
more favourable than if any part of it 
be carious. But in whatever ftate the 
Jj>ones may be, our treatment of the fore 
rnuft be the fame : we muft endeavour 
to cure it as nearly as poflible by the 
firft intention : For which purpofe, after 

re- 



Seel. VII. at the Hip- Joint. 393 

removing all the coagulated blood from 
the furface of the wound ; placing the 
mufcles as nearly as poffible in their na- 
tural fituations ; and drawing the two 
flaps together, fo as to cover the fore as 
neatly as may be : they mould be fecured 
in this fituation by three or four futures 
introduced at the moft proper points; 
by adhefive plafters ; and by proper com- 
prefTes retained with a broad flannel rol- 
ler pafTed different times round the body, 
and fpirally over the flump ; care being 
taken to leave the ligatures upon the ar- 
teries of a fufficient length to admit of 
their being afterwards drawn out. 

The patient mould now be laid in bed, 
and treated in other refpecls as we have 
advifed in general after the Operation of 
Amputation : Only it muft be remarked, 
that more than ordinary attention will 
be required to prevent and remove fuch 
febrile fymptoms as ufually fuCceed to 
amputation ; for where fuch a consider- 
able part of the body is fuddenly taken 
away, almofl a fourth part of the whole, 

Vol. VI. C c we 



J94 Of -Amputating Ch. XLIIL 

we may reafonably conclude that the ef- 
fect produced by it upon the fyftem muft 
be confiderable. If the patient is ple- 
thoric, it will be proper to diminifh the 
quantity of blood ; in the firft place by 
vensefection, and afterwards by a low 
diet : Indeed moderate living fhould be 
perfevered in, if not for life, at leaft for 
a great length of time. 

The dremngs may be removed at the 
ufual time, and in the courfe of ten or 
twelve days the ligatures may be all ta- 
ken away ; when any part of the fore that 
remains open may be covered, by draw- 
ing the fkin over it, and fecuring it with 
adhefive plafter. In fuch an extenfive 
fore, it is indeed probable that matter 
may collect in different parts beneath 
the fkin ; for the prefTure applied upon 
it, will not be fo equal as in common 
cafes of amputation : but the inconve- 
nience arifing from this will not be 
great ; for if the matter cannot be dis- 
charged by altering the prefTure, it will 
be eafily done with the point of a lan- 
cet* 



Sect. VII. at the Hip- Joint. 395 

cet, by which this obltruction to the cure 
will be removed. 

At all times this will neccfTarily be 
confidered as a very formidable opera- 
tion : But when performed in the man- 
ner we have advifed, much of the ha- 
zard, and many of the inconveniences 
ufually fuppofed to attend it, will be re- 
moved : nor mould any practitioner ac- 
cuftomed to operate, heiitate in perform- 
ing it, when the life of a patient will 
otherwife be endangered. By the tour- 
niquet, we effectually command the cir- 
culation in the limb till all the large 
blood-veffels divided by the circular in- 
cifion are tied ; and by fecuring the dif- 
ferent arteries that are cut in making 
the longitudinal incifions as foon as they 
appear, the lofs of blood will be incon-^ 
fiderable : Nor will there be any rifle of 
hurting the femoral artery in the courfe 
of feparating the flap in which it is feat- 
ed from the bone, if it be done with 
caution. 

It may be alleged, that by this method- 
C c 2 ©£ 



396 Of Amputating Ch. XLIII. 

of operating, more of the teguments and: 
mufcles will be faved than are necefTary 
for covering the fore ': But it muft be re- 
membered, that the fore will here be 
very extenfive, and that the divided muf- 
cles will retract considerably. And be- 
fides, the tourniquet could not be ap- 
plied if the firft cut was much higher 
than we have directed ; by which the 
operation would neceffarily be rendered 
much more dangerous : Nor can any rifk 
occur from the teguments and mufcles 
being left fomewhat longer than might 
be J uft required for the purpofe above 
mentioned, while much inconvenience 
would enfue from their being deficient. 

In the fixth volume of the Medical 1 
Commentaries of Edinburgh, a cafe is 
recorded, in which the thigh was ampu- 
tated at this joint by Mr Kerr furgeon 
in Northampton. In this cafe, the divi- 
fion of the femoral artery was referved 
to the lafl 5 nor was the tourniquet em- 
ployed. No hemorrhagy indeed occur- 
red j 



Seel. VII. at the Hip-Jo'mh 397 

red ; but there was furely more rifk of 
this than if the operation had been done 
in the manner we have advifed : Nor 
could the operator ufe fuch freedom with 
the bone, in removing the head of it from 
the focket, as long as the blood-vefTels 
remained undivided. We may remark, 
however, that this cafe affords an in- 
flance of this operation being practifed 
with fafety : For although the patient 
died, yet (he lived eighteen days after 
the operation, and at lafi died from a 
different caufe, when all rifk of hemor- 
rhagy was over, and when the fore had 
even a favourable appearance. 



Cc3 SEC- 



398 Of the Flap Operation Ch. XLIII. 



; SECTION VIII. 



Of the Flap Operation immediately above the 
Knee. 



WHEN this operation is to be per- 
formed above the knee, it may be 
done either with one or two flaps, but it 
will commonly fucceed befl with one. 
It is moft convenient to have the flap on 
the fore-part of the thigh ; for 1 here there 
is a fufheiency of foft parts for covering 
the bone, and the matter paffes more 
freely off than when the flap is formed 
in any other direction, 

The patient being placed upon a table, 
the tourniquet being applied in the 
ufual way at the top of the thigh, and 
the teguments drawn firmly up and re- 
tained by an affiftant, the extent of the 
intended flap fliould be marked with ink, 

h 



Seel. 'VIIL above the Knee. 399 

A perfon much accuflomed to this ope- 
ration may not require this affirmance ; 
but it will be done with more ncatnefs 
and exaclnefs if the form and extent of 
the flap be previoufly marked. 

The extreme point of the flap fhould 
reach to the end of the limb, unlefs the 
teguments be in any part difeafed ; in 
which cafe, it muft terminate where the 
difeafe commences, and its bafe fhould 
be where the bone is to be fawn. This 
will determine the length of the flap ; 
and we muft be directed with refpecl to 
the breadth of it by the circumference 
cf the limb : For, the diameter of a cir- 
cle being fomewhat more than a third 
of its circumference, although a limb 
may not be exactly circular, yet by at- 
tention to this circumftance, we may as- 
certain with fiifficient exaclnefs the fize 
of a flap for covering a flump. Thus, a 
flap of four inches and a quarter in length 
will reach completely acrofs a flump 
whofe circumference is twelve inches ; 
but as fome allowance mufl be made for 
Ccj the 



40O Of the Flap Operation Ch.XLIII. 

the quantity of Ikin and mufcles that 
may be faved on the qppofite fide of the 
limb, by cutting them in the manner we 
have directed, and drawing them up be- 
fore fawing the bone ; and as it is a point 
of importance to leave the limb as long 
as poflible, inftead of four inches and a 
quarter, a limb of this fize, where the 
firft incifion is managed in this manner, 
will not require a flap longer than three 
inches and a quarter, and fo in pro- 
portion according to the fize of the limb. 
The flap at its bafe mould be as broad 
as the breadth of the limb will permit, 
and fhould be continued nearly, although 
not altogether, of the fame breadth to 
within a little of its termination, where 
it fhould be rounded off fo as to corre- 
spond as exactly as may be with the fi- 
gure of the fore on the back part of the 
limb. This being marked out, the fur- 
geon Handing on the outfide of the limb 
fhould pufh a flraight double-edged knife 
with a fharp point to the depth of the 
bone, by entering the point of it at the 

outfide 



Sect. VIII. above the Knee. 401 

outride of the bafe of the intended flap ; 
and carrying the point clofe to the bone, 
fhould pufh it through the teguments at 
the mark on the oppofite fide. The edge 
of the knife muft now be carried down- 
wards, in fuch a direction as to form the 
flap according to the figure marked out ; 
and as it draws towards the end, the edge 
of it fhould be fomewhat raifed from the 
bone, fo as to make the extremity of 
the flap thinner than the bafe ; by which 
it will apply with more neatnefs to the 
furface of the fore. The flap being fup- 
ported by an afliftant, the teguments and 
mufcles on the back part of the limb 
fhould, by one ftroke of the knife, be cut 
down to the bone about an inch beneath 
where the bone is to be fawn ; and the 
mufcles being feparated to this height 
from the bone with the point of the 
knife, the foft parts muft all be fupport- 
ed with the leather' retractors, Plate 
LXXXIV. fig. 4. till the bone is fawn ; 
and any fplinters that may be left, are 

cut 



4G2 Of tbe'Flap Operation Ch. XLIII. 

cut off. All the arteries that difcharge 
much blood muft now be fecured in the 
ufual way with the tenaculum, the liga- 
tures being left of a fufficient length 
for hanging out at the edge of the 
flap. 

The mufcles and teguments fhould 
now be drawn down and fecured with a 
flannel or cotton roller, in the manner 
we have advifed when a leg is amputated 
with a circular incifion ; and the flap 
may now be laid down over the furface 
of the fore, fo as to effect a cure as much 
as poflible by the flrft intention ; or it 
may be dreffed as a feparate fore, agree- 
able to the practice of Mr O'Halloran, 
according to the judgement of the opera- 
tor. If it is to be applied immediately, 
the coagulated blood fhould be carefully 
fponged out, and it fhould be fecured to 
the mufcles and teguments furrounding 
the reft of the flump by three or four fu- 
tures paffed at leaft three quarters of an 
inch into the mufcular fubftance of the 
flap : But care fhould be taken not to 

draw 



Sect. VIII. above the Knee. 403 

draw the ligatures fo tight as to create 
much irritation or pain. The under part 
of the flump mould now be covered with 
a large pledgit of common cerate ; and a 
cufhion of foft tow being laid over it, the 
whole mould be fecured in the manner 
we have formerly advifed, with crofs 
(traps of linen and a few turns of a 
circular roller. 

In three or four days the dreflings 
may be renewed ; and as foon as the 
ligatures are all removed, and the ten- 
sion and inflammation induced by the 
operation abated, any part of the fore 
which was not covered at nrft may now 
have the fkin drawn over it, and fecured 
with adhefive platters. 

But if Mr O'Halloran's method is to 
be adopted, the eafieft mode of proceed- 
ing is this. The mufcles and teguments 
being drawn down and fecured with the 
roller, let the whole furface of the flump 
be covered with a pledgit of foft lint 
fpread on both fides with any foft emol- 
Jient ointment : Let the flap be laid 

down 



404 Of the Flap Operation Ch.XLIIL 

down upon this ; and another pledgit of 
the fame kind being laid over the whole 
with a culhion of tow and a comprefs of 
foft linen, the crofs ftraps and circular 
roller mould be employed to* fupport 
them, but with no more preffure than is 
neceffary for this purpofe. At the end 
of three or four days the dremngs may 
be renewed in the fame manner ; and 
about the twelfth or fourteenth day, or 
whenever the tenfion induced by the 
operation is removed, the ligatures all 
taken out, and a proper fuppuration 
eftablifhed, the flap may be brought into 
contact with the fore beneath with a 
view to make them unite. For this pur- 
pofe, any matter that may be obferved 
upon the furface of either of them mould 
be gently removed with a foft fponge ; 
and the flap being laid down with as 
much exaclnefs as pomble, it may either 
be fecured with adhefive plafters fup- 
ported by the bandage above mentioned, 
or two or three futures may be employ- 
ed. This laft method will give more 



Sect. VIII. above the Knee. 405 

pain than the other j but this will be 
amply compenfated by the flap being re- 
tained in its fituation with much more 
certainty and exactnefs. 

Farther experience mud evince which 
of thefe methods mould be preferred, 
for as yet it is not determined. It is 
my own opinion, that the fecondary 
union recommended by Mr O'Halloran 
is the beft : for the pain, tenfion, and in- 
flammation which enfue from the other, 
run often fo high as to render it necef- 
fary to remove the dreffings and even 
the ligatures ; by which a great deal of 
additional trouble is given to the practi- 
tioner and much diftrefs to the patient : 
whereas, when the tenfion and inflamma- 
tion are gone before the flap is laid down, 
little or no pain is induced by it ; nor is 
the cure effected in this manner more 
tedious : On the contrary, it would appear 
to be in general accomplifhed more 
quickly in this way than in any other. 
Even where the flap has not been ap- 
plied 



406 Of the Flap Operation Ch.XLIIL 

plied to the fore till the fourteenth day, 
the cure has been completed before the 
fourth week : Whereas few, if any, cures 
have been effected fo early where the 
flap has been applied immediately after 
the operation. 

In operating with two flaps, the fol- 
lowing is perhaps the eafiefl method : 
The patient being placed upon a table, 
and the tourniquet applied, let the Ikin 
be drawn up by an amftant, and a cir- 
cular incifion be made through the te- 
guments and mufcles down to the bone 
at the moft inferior parts of the limb, 
with the edge of the knife turned ob- 
liquely upwards : Let the fharp-pointed 
knife, mentioned above, be now pufhed 
through the fkin and mufcles on one 
fide of the limb down to the bone, at that . 
part where the bone is to be fawn ; and 
the under edge of the knife being turn- 
ed obliquely outwards, let the mufcles 
be divided down to the circular incifion. 
The teguments and mufcles on the op- 
pofite fide of the limb muft now be di- 
vided 



Sect. VIII. above the Knee. 407 

vided by a fimilar incifion, when any of 
the intermediate foft parts that may 
have been left mult .like wife be cut ; 
and the bone being fawn, and the vef- 
fels fecured with ligatures, the cure may 
either be attempted by laying the flaps 
together immediately, or they may be 
kept feparate twelve or fourteen days, 
and treated afterwards in the manner we 
have advifed above. 



SECTION IX, 



Of the Flap Operation below the Knee. 



IN fpeaking of this operation below 
the knee, it is not necefTary to de- 
fcribe all the fteps of it. The views of 
the operator are the fame here as in 
operating above the knee, and the me- 
thod of effecting them is nearly fimilar. 

After 



408 Of the Flap Operation Ch. XLIIL 

After the previous fteps of the operation 
are taken, the fize and form of a flap fuf- 
ficient to cover a confiderable part of the 
fore muft be marked out with ink ; this 
mult be feparated from the parts be- 
neath in the manner we have already 
advifed : The reft of the foft parts 
muft be divided, taking care to fave 
as much of the teguments on the fide of 
the limb oppofite to the flap as with the 
flap itfelf will nearly or entirely cover 
the fore ; and the cure muft afterwards 
be conducted either by applying the flap 
immediately, or after the fymptoms of 
pain, tenfion, and inflammation induced 
by the operation are gone, and treated 
in the manner we have advifed in the 
laft fection. 

It muft be obferved, however, that in 
operating beneath the knee, the flap can- 
not be formed on the fore-part of the 
limb as is done in the thigh ; for on this 
part of the leg there is no mufcular fub- 
ftance ; and for this reafori, we are ad- 
vifed by authors to form the flap on the 

back- 



Sect. IX. belozv the Knee f 409 

back part of the leg. But this is liable 
to one very important objection, the 
difficulty of preventing matter from 
lodging between the flap and the fore 
after they are brought into contact : for 
it muft be remarked, that it is moderate 
prefTure only which we dare venture to 
apply to the flap j fo that it is fcarcely 
poflible to prevent the matter from col- 
lecting where it does not find a free 
vent below. 

Inftead of forming the flap from the 
mufclesofthe back part of the leg, it 
may be done with more propriety upon 
the outiide of the limb, where there is 
a fufficient quantity of mufcular fub- 
ftance for this purpofe. The point of the 
knife mould be entered on the outfide 
of the ridge of the tibia at the part 
where the bone is to be fawn ; and being 
carried backwards in a direct line, and 
at a proper depth to the oppoiite fide of 
the bafe of the flap, the edge of it muD: 
afterwards be carried down the line pre- 
vioufly marked with ink as a direction 

Vol. VI. D d for 



41 o Of the Flap Operation. Ch.XLIIL 

for the form and length of It. In this 
manner the bones may be covered with 
a flap of a fufficient thicknefs, while the 
matter which forms in the progrefs of 
the cure, finding a ready outlet by the 
inferior edge of the flap, will not be 
allowed to lodge. 

In operating immediately above the 
ankle, there is a neceflity for leaving 
die flap behind, for there is not a fuffi- 
cient quantity of foft parts to admit of 
it in any other fituation. But we have 
elfewhere obferved, that the leg mould 
never be taken off fo immediately a- 
bove the ankle, as it leaves the flump 
too long for a machine to be rightly 
adapted to it for the purpofe of walk- 
ing : But at nine inches from the con- 
dyles of the femur, which in an adult is 
the moft proper length for this purpofe, 
the flap may with propriety be formed* 
in the manner we have mentioned, 
ihe outfide of the leg. 



SEC 



Sect. X. Of Amputating the £sV. 411 



SECTION X. 



Of Amputating the Foot, Hoes', and Fingers, 



WHEN the whole foot is difeafed, it 
becomes neceffary to take off the 
limb at the part we have mentioned 
above the ankle ; nay, this fhould be 
done even where the parts about the 
joint are found, if all the reft of the 
foot is difeafed : For although fome have 
recommended the amputation of the foot 
at the joint of the ankle, yet the practice 
fhould not be adopted, as the fore can- 
not be properly covered, nor is the 
ftump when of this length fo ufeful : But 
when any confiderable part of the foot 
remains found, it ought undoubtedly to 
be faved, and the difeafed part of it only 
removed. I have feen a whole foot takeii 
B d 2- 0% 



412 On Amputating the Ch.XLHT„ 

off, where two of the metatarfal bonea 
only have been difeafed : while, on the 
contrary, it mould be laid down as a fix- 
ed rule, to remove the difeafed parts 
alone, even where two of thefe bones 
Only remain found ; for with the affifl- 
ance of a fhoe properly fluffed, and with 
a firm unyielding fole, even a very fmall 
part of the foot proves ufeful in walk- 
ing : And this efpecially when the bones 
on the infide of the foot, or thofe cor- 
refponding to the great toe and thofe 
next to it, are left. 

When the middle part only of the 
foot is difeafed, the metatarfal bones on 
each fide remaining found, thefe mould 
be left, and the difeafed part only taken 
out. In this cafe, the affected bone* 
fhould be taken out at the joint whether 
they be difeafed through their whole 
length or not ; for although inflruments 
might be invented for cutting even a 
fmgle bone acrofs in the centre of the 
foot, the operation /would necefTarily be 
much more tedious,, and more painful, 

than 



Sect. X. Footy Toes, a?id Fingers. 413 

than the removal of the bone at the 
joint, at the fame time that little or no 
advantage would be derived from faving 
a fmall portion at the end of it. But 
where one, two, or three of the bones 
on either fide of the foot are only par- 
tially difeafed, as in this cafe it becomes 
an object to fave as much of the foot as 
poflible, the operation mould be fo con- 
dueled that the bones may be fawn a- 
crofs nearly at the termination of the 
difeafed parts. 

In every cafe of amputation, it is an ob- 
ject of importance to fave as much fkin as 
will cover the fore ; but it is particular- 
ly neceflary in amputating any part of 
the foot where the effect of friction is 
much to be dreaded in walking. In ma- 
king the incifion, therefore, at that part 
of the bone where the faw is to be ap- 
plied, it mould be done in fuch a man- 
ner, that a flap may be faved of a fuffi- 
cient fize for covering the fore. With a 
little attention this may always be done, 
nor is it often attended with any diffi- 
P d 3 cultv • 



414 Of -Amputating the Ch . XLIII. 

culty ; for the flap may be formed either 
above or below, or on one fide of the toe, 
according as the teguments are found or 
other wife. But it is proper to remark, 
that where the fkin is found, it anfwers 
t>eft to fave it below ; as in this fituation 
it is firmer, and therefore more able to re- 
fift the effects of preffure. 

This operation is moft eafily perform- 
ed when the patient is placed upon a 
table. The tourniquet fhould be applied 
above the knee, with a comprefs placed 
upon the artery in the ham j the limb 
fhould be firmly fecured by afftftants ; 
and on fawing the bone, a piece of pafte- 
board, or thin fplint of timber, fhould be 
inferted between it and the contiguous 
found bone, to protect the latter from 
the teeth of the inftrument. 

The difeafed parts being removed, 
and any artery that is cut fecured, the 
flap fhould be applied as exactly as pof- 
fible to the fore, and retained with flips 
of adhefive plafter and gentle preffure 
with a flannel roller. If futures are em- 
ployed. 



Sect. X. Foot, Toes, and Fingers. 415 

ployed, they fhould be inferted in fuch 
a manner as to avoid the flexor and ex- 
tenfor tendons of the toes and foot. 

In amputating the toes and fingers, 
the operation ufed formerly to be done 
by one ftroke with a chifel and mallet ; 
but this is liable to many objections, 
and has been long in difufe. In general, 
fingers and toes are amputated in the 
fame manner with the larger extremities, 
either by preferving a flap fufEcient 
for covering the fore, and afterwards di- 
viding the bone with a fmall fpring faw 
reprefented in Plate LXXXIV. fig. 1. or 
by the double incifion, performed in the 
manner we have advifed in Section IV. 
of this Chapter. But inftead of this, it 
has for /everal years been the practice of 
fome individuals, to amputate fingers and 
toes at the joints ; and whoever will 
give it a fair trial, will readily prefer it, 
The patient being placed upon a table, 
and the limb properly fecured, a flap 
mould be marked with ink of a fufE- 
cient fize for covering the fore. This 
D d 4 being 



41 6 Of Amputating tht Ch. XLIII. 

being diffected from the bone with a 
fcalpel, and fupported by an afliftant, a 
circular incifion fhould be made through 
the reft of the foft parts, a little below 
the joint, and on a line with the bafe 
of the flap. The lateral ligament 
fhould now be cut ; and in order .to de- 
termine the point at which this mould 
be done, an afliftant fliould be directed 
to move the finger. This ligament be- 
ing divided, the joint is eafily diflocated, 
when the remainder of the operation 
may be quickly finifhed. If it is necef- 
fary to tie an artery, it fhould be done 
with the tenaculum. The flap muft be 
applied to the fore, and fecured as neat- 
ly as poflible with adhefive plafters, and 
moderate prefTure with a flannel rol- 
ler. 

The only objection that has been made 
to this practice is, the fuppofed uncer- 
tain union of the contiguous foft parts 
with cartilage. But we now know, that 
there is no caufe for this apprehennon, 
and that a flap will unite as readily with 

cartilage 



Sect. XI. Arm at the Shoulder. 417 

cartilage as with bone, at leaft I have 
uniformly obferved this to be the cafe ; 
and we find from Mr Alanfon's publica- 
tion, that the practice has proved very 
fuccefsful in the courfe of his experi- 
ence. 



SECTION XT. 



Of Amputating the Arm at the Joint of the 
Shoulder. 



THIS operation having always been 
confidered as hazardous and diffi- 
cult to perform, it has not frequently 
been attempted : But although it mould 
never be advifed when our purpofe can 
be accomplifhed by amputating lower, 
yet no practitioner of modern times will 
decline it, when the life of a patient can?- 
not in any other manner be faved. Ab* 

feeffes 



41 8 Of Amputating the Ch. XLIII. 

fcefles in the joint, caries of the humerus 
reaching to the joint, compound frac- 
tures extending to the head of the bone, 
gunfhot wounds and mortification, may 
render amputation of the arm at the 
fhoulder necefTary. 

The operation may be performed with 
fafety by any furgeon of fleadinefs and 
experience, and who is poflefled of an 
accurate knowledge of the anatomy of 
the joint and contiguous parts. 

It may be done in different ways ; 
but the following I believe to be the 
beft. 

The patient mould be placed upon a 
table of a convenient height, covered 
with a matrefs and blanket ; and he fhould 
be laid upon his back, and properly fe- 
cured by afliftants, as near as pofhble to 
one fide of -the table. 

The next object is to guard againft 
hemorrhagy : for this purpofe we might 
advife the tourniquet to be placed upon 
the upper part of the limb, in a manner 
fimilar tp what we have propofed in am- 
putating 



-Sect. XI. Arm at the Shoulder, 419 

putating at the hip-joint. But here it is 
unneceflary, as the blood may be com- 
pletely flopped in its flow to the arm, 
by comprefling the fubclavian artery as 
it panes over the firfl rib : for this pur- 
pofe, an afliflant mould be properly pla- 
ced, with a firm cufhion or comprefs ap- 
plied upon the courfe of this artery di- 
rectly above the clavicle, who with his 
fingers mould make fuch a prefTure as 
may be necefTary : It will readily be 
known whether it proves effectual or 
not, by its influence on the pulfation at 
the wrift. 

The circulation being flopped, the 
difeafed moulder mould be made to pro- 
ject fomewhaj; over the fide of the table ; 
and the arm being flretched out and fup- 
ported by an afliftant at nearly a right 
angle with the body, a circular incifion 
mould be made through the fkin and 
cellular fubftance jufl at the infertion of 
the deltoid mufcle into the humerus. The 
teguments may be allowed to retract a- 
jbout half an inch j and at the edge of the 

retracted 



420 Of Amputating the Ch. XLIII. 

retraced ikin, the knife may be applied 
fo as to divide the mufcles with a per- 
pendicular circular cut down to the bone. 
Thus far we proceed with the common 
amputating knife ; but the remainder of 
the operation Ihould be finifhed with a 
fcalpel. With a firm round-edged fcalpel 
a perpendicular incilion fhould now be 
made down to the bone, commencing at 
the acromion, about half way between 
the centre of the deltoid mufcle and 
the inner edge of it, and terminating 
in the circular incifion about an inch 
above, or rather on the outfide of the 
brachial artery. This being done, a fi- 
milar cut muft be made on the back 
part of the arm, commencing at the fame 
height with the other, and ending in 
the circular inciiion. This mould be at 
fuch a diftance from the firft, that the 
two flaps formed by them both may be 
nearly of an equal breadth. The bra- 
chial artery mould be tied as foon as it 
is cut by the circular incifion through 
the mufcles ; and any anaflomofing muf- 
jcujlar branches of arteries that may be 

cut 



Sect. XI, Arm at the Shoulder, 421 

cut on the upper and back part of the 
joint fhould be tied immediately on being 
obferved. The two flaps mould now be 
feparated from the bone, care being ta- 
ken to avoid the large artery in differ- 
ing off that part of the flap with which 
it is connected. An afliftant muft fupport 
the flaps fo as to bring the capfular liga- 
ment of the joint into view ; when an 
opening being made into it, the head of 
the bone will be eafily difloeated by 
drawing the arm backward ; and this 
being done, the operation will be eafily 
finifhed by dividing the remaining part 
of the ligament. 

Any arteries that may have been cut 
about the joint being tied, the ligatures 
hanging out at the moft depending part of 
the wound, and the parts cleared of coa- 
gulated blood, the two flaps fhould be 
laid together fo as to cover the joint as- 
neatly as poflible, and retained in their 
fituation by two or more futures. A 
pledgit of lint fpread with any emollient 
ointment fhould now be laid over the 

joint ; 



422 Of Amputating the Ch. XLIIIv 

joint ; and a foft cufhion of tow or of 
lint, with a comprefs of old linen, being 
applied over the whole, a flannel roller 
fhould be employed to make a moderate 
prefTure upon the joint ; by which the 
flaps will be kept in contact with the 
parts beneath, which will not only fa- 
cilitate their union, but will be the moft 
effectual method of preventing matter 
from lodging. 

In other refpects, the patient fhould 
be treated as we have advifed in the 
preceding Sections, when fpeaking of 
Amputation in the Lower Extremities. 
With a view to prevent any ri£k from 
hemorrhagy after the operation, an af- 
firmant of experience fhould lit with the 
patient for the firft two or three days, 
with directions to apply prefTure above 
the clavicle in the event of any confider- 
able quantity of blood being difcharged, 
till the bleeding veflel can be fecured 
with a ligature. In the courfe of eight 
or ten days the ligatures upon the ar- 
teries will come eafily away. If matter 

collects 



Sect. XI. Arm at the Shoulder^. 423. 

collects beneath any part of the fkin, k 
mud be difcharged ; and if the patient 
is healthy and no untoward circumftance 
happens, a cure may foon be expected. 

Till of late, it was the practice in this 
operation to tie the brachial artery and 
veins with a ligature before proceeding 
farther. This gave much unneceffary 
pain, at the fame time that it did not 
render the patient more fecure. In the 
way we have mentioned, the operation 
may be performed with no rifk from 
the hemorrhagy ; and by tying the ar- 
tery at the extremity of the flap, feve- 
ral mufcular branches will be faved which 
would be cut off by tying it near the 
axilla. 

Mr Bromfield, in the firft volume of 
his Obfervations and Cafes, has given the 
beft account yet publifhed of this opera- 
tion. The principal difference between 
this method of doing it and the one we 
have defcribed, confifts in the latter 
being more fimple, and therefore more 
eafily performed. By dividing the muf- 

cles 



4H Of Amputating the Ch.XLIIL 

cles down to the bone with a circular in- 
cifion, the operation is more fpeedily 
done than by cutting firft one mufcle and 
then another, in the manner mentioned 
by Mr Bromfield. And as the attach- 
ments of the latiffimus dorfi, the deltoid 
and pectoral mufcles, as well as of all 
the other mufcles of the arm, are re- 
moved by the arm being taken away, 
there is no neceflity for proceeding with 
flownefs and caution in dividing them j 
nor is it neceflary to employ two liga- 
tures npon the brachial artery j one con- 
siderably higher than the other, as is ad^ 
vifed by that author ; one ligature "ap- 
plied in the ufual way with the tenacu- 
lum is quite fufficient, if it be done with 
care and attention. And Mr Alanfon 
verly properly obferveSj in fpeaking of 
this operation, that there is no neceflity 
for fcraping off the cartilage from the 
acetabulum of the joint, as is recom- 
mended by Mr Bromfield ; for we find 
by experience, as we have obferved in 

the 



5ect. XII. the Amu 425 

the laft Seclion, that the teguments ad- 
here to cartilages as readily as to bone. 



SECTION XII. 

Of Amputating the Arm. 

THE general obfervations we have made 
upon the method of amputating the 
thigh and leg, apply with the fame proprie- 
ty to the amputation of the arm and fore- 
arm. At prefent, therefore, we fhall only 
obferve, that in amputating the arm, no 
more of it mould be removed than is dif- 
eafed ; for the longer the (lump is, the 
more ufeful it proves : And the fame at- 
tention mould be given to the faving of 
teguments for covering the fore that we 
have advifed in Amputating the Leg, 
But it is proper to remark, that this may 
always be done both in the arm and fore- 
arm without the afliftance of a flap : For 
there is in every part of both a fufEciency 
Vol. VI, E e both 



41 6 Of Amputating, &>c. Ch.XLIII. 

both of mufclcs or cellular fubftance, 
for admitting of the fore being com- 
pletely covered by amputating with the 
double incifion, in the manner we have 
pointed out ; and wherever this can be 
done, it mould be preferred to the me- 
thod of operating with a flap. 



CHAP. 



CK.XLIV. Of removing Ends of Bones, 427 



CHAP. XLIV. 



Of removing the Ends o/* Bones in Dfeafes 
of the Joints. 



THE amputation of limbs is more fre- 
quently advifed for affections of 
the joints than for any other caufe ; and 
as this often happens where the reft of 
the limb is found, it were to be wifhed 
that with fafety and propriety we could 
remove fuch parts as are difeafed, and 
leave thofe that are found. In compound 
fractures and diflocations, the ends of 
large bones have frequently been fawn 
off, when fuch parts of them have pro- 
E e 2 truded 



428 Of removing Ends of Ch.XLlV. 

traded as could not be replaced. The 
deficiency thus produced, has in moft 
kiftances been fupplied by nature ; and 
thus the limbs have remained almoft 
equally ufeful as before. In a few cafes 
too of difea£ed joints, a cure has been 
obtained by the head of a bone being 
fawn off. Among other inftances of this 
to be met with in books, a remarkable 
one is recorded by a very ingenious and 
expert furgeon, Mr White of Manchefter, 
who preferved an arm by fa wing off the 
head of a difeafed humerus *.. But Mr 
Park of Liverpool was the firft who ven- 
tured to propofe it as a general remedy 
in affections of the joints f. Whether or 
not it will (land the teft of experience, 
farther trials muft determine ; but in 
the mean time, the public are much in- 
debted ta Mr Park for the pains he has 

taken 

* Vide Cafes in Surgery with Remarks, Part I. by 
Charles White, F. R. S. &c. 

-f- Vide An Account of a New Method of Treating 
Difeafes of the Joints of the Knee and Elbow,, by H. 
Park. 



Ch. XLIV, Bones at the Joints. 429 

taken to introduce a lefs formidable re- 
medy in place of .amputation. 

What Mr Park propofes is, that in- 
flead of amputating a limb for any exter- 
nal violence done to a joint, for a white 
fwelling, a caries, or any other affection, 
that the difeafed ends of the bones 
fhould be fawn off; when nature, he 
thinks, will commonly fupply the de- 
ficiency of bone ; by which the limb will 
be preferved, and will prove more ufe- 
ful than any machine that artifts can 
invent. 

Mr Park fiippofes that this operation 
will be chiefly applicable to affections of 
the knee and elbow, and more particu- 
larly to thofe of the latter ; and he relates 
a cafe of white fwelling of the knee in 
which it was practifed with fuccefs : The 
under extremity of the femur and the 
upper end of the tibia were fawn off; 
no artery of importance was injured ; 
the vacancy produced by the removal 
of the ends of the bones was fupplied 
with callus : in the courfe of ten weeks 
a cure of the fore was obtained; the 
E e 3 limb 



430 Of removing Ends of Gh.XLIV. 

limb became fo firm that the man has 
fince been able to go to fea as a failor, 
and he does not even ufe a crutch. 

This, however, is the molt favourable 
view of the propofal ; and it is proper to 
remark, that in the courfe of the cure, 
much perplexity occurred from various 
circumftances ; particularly from the 
difficulty of preferving the limb in a 
fteady fixed fituation j from the great 
depth of the wound ; from the lodge- 
ment of matter ; and from the formation 
of finufes. By much attention on the 
part of Mr Park, all thefe difficulties 
were furmounted : But although the 
merits of the operation muft be deter- 
mined by farther trials, yet the rifk at- 
tending it appears to be fo great, that 
£here is much reafon to fufpecl: that it 
will never be generally praclifed. 

For a more particular detail of the me- 
thod of doing it, and of the after-treat- 
ment of the fore, the publication itfelf 
muft be confulted ; but for the advantage 
of thofe who may not eaiily meet with 



Gh.XLIV. Bones at the Joints. 431 

it, the following fhort account of the 
operation is inferted in Mr Park's own 
words. 

" An incifion was made, beginning 
about two inches above the upper end 
of the patella, and continued about as 
far below its lower extremity : Another, 
crofling this at right angles, immediately 
above the patella, the leg being in an ex- 
tended ftate, was made through the ten- 
dons of the extenfor mufcles down to the 
bone, and nearly half round the limb ; 
the lower angles formed by thefe inci- 
fions were raifed fo as to lay bare the 
capfular ligament : The patella was then 
taken out, and the upper angles were 
raifed, fo as fairly to denude the head of 
the femur, and to enable me to pafs a 
fmall catlin acrofs the pofterior flat part 
of the bone immediately above the com- 
dyles, taking care to keep one of the 
flat fides of the point of the inftru- 
ment quite clofe to the bone all the 
way. The catlin being withdrawn, an 
elaftic fpatula was introduced in its 



43 2 Of removing Ends of Gh.XLrV. 

place, to guard the foft parts while the 
femur was fawing through : Which done, 
the head of the bone thus feparated was 
carefully difTected out ; the head of the 
tibia was then with eafe turned out and 
fawn off, and as much as poifible of the 
capfular ligament difTected away, leaving 
only the pofterior part covering the vef- 
fels ; which, on examining, I had the fa- 
tisfaction to find had not only efcaped 
unhurt, but that it was not a very nar- 
row efcape : They had ftill a pretty good 
covering, and had been through the 
whole operation far enough out of the 
"courfe of the knife. It muft be confefTed, 
that the appearance of the wound was 
fomewhat formidable, exhibiting a very 
large cavern with very thin pa^ietes ; and 
in ihort, there feemed little wanting to 
complete the amputation : Yet as the 
limb below would not be deprived of 
any part of its nourifhment, and as eve- 
ry healthy incifed furface, as well of 
bone as of foft parts, has a natural ten- 
dency to granulate, I could not fee any 

room 



Oi. XLIV. Bones at the Joints. 433 

room to doubt that nature would be able 
to repair the breach." 

Mr Park afterwards informs us, that he 
attempted to perform the operation with- 
out making the tranfverfe incifion : But 
he found it could not be done ; and after 
{pending fome time in the attempt, it 
was thought advifable to defift from it. 
More than two inches of the femur, and 
rather more than one inch of the tibia, 
were removed ; which were but jufl e- 
nough to admit of the leg being brought 
into a right line with the thigh, the pre- 
vious contraction of the flexor mufcles 
being fuch as to keep the two fawn ends 
of bone in clofe contact : This produced 
a eonfiderable redundance of the tegu- 
ments. To fupport this, that it might 
not fall inward, and to keep the edges 
of the incifion in appofition till they 
fhould acquire fome degree of firmnefs, 
a few flitches were pafTed through the 
fkin ; not merely along the courfe of the 
tranfverfe incifion, but upon that part of 
the longitudinal cut that extended up 

the 



434 Of removing Ends of Ch,XLlV. 

the thigh. The lighteft fuperficial dref- 
fings only were applied, and the limb 
placed in a cafe of tin from the ankle 
to the infertion of the gluteus mufcle. 

Mr Park very candidly enumerates fe- 
veral objections which may be made to 
this operation ; but at the fame time, he 
thinks that all of them may be obviated. 
There are two, however, which, in my 
opinion, will always appear with force 
jagainft it : The flrft is, that where the 
bones of large joints are fo much difea- 
fed as to render it necefTary to remove 
them, the furrounding foft parts are 
for the mofl part fo much thickened, 
inflamed, or ulcerated, as to render any 
attempt to fave them very" uncertain, 
and much more ha'zardous than the am- 
putation of the limb : And the fecond is, 
the high degree of inflammation which 
commonly fucceeds to wounds of the 
larger joints. 

With refpect to the firft of thefe, Mr 
Park himfelf wifhes it to be underftood, 
that ^t is chiefly in affections of the joint6 

pror 



,Ch. XLIV. Bones at the Joints. 435 

produced by external violence, that he 
thinks this operation will be peculiarly 
ufeful ; and with refpect to the laft, he ob- 
ferves, that the heads of large bones have 
been frequently fawn off, without any 
violent fymptoms enfuing : and as he 
fuppofes this to be owing to the very free 
diviiion of the capfular ligaments, which 
in fuch cafes mull always take place, he 
thinks that the total removal of this li- 
gament, which he advifes in this opera- 
tion, will in a great meafure prevent 
it. We have obferved above, that ex- 
perience alone can determine upon the 
merits of this operation ; but we cannot 
avoid remarking, that no neceflity ap- 
pears for the removal of any part of the 
capfular ligament. It may be highly 
proper to make the opening into it free 
and large ; but to remove it, by diflecl:- 
ing it off from the contiguous parts, mud 
probably add to the rifk of the opera- 
tion, by rendering the inflammation 
more fevere than it otherwife might be ; 
at the fame time that it rauft neceflarily 

render 



436 Of removing, <&c. Ch. XLIV. 

render it much more painful as well as 
more tedious. Farther experience may 
perhaps fet this in a different point of 
view : but at prefent we fee no more rea- 
fon for removing any part of the capfu- 
lar ligament in this operation, than for 
the removal of the tunica vaginalis teftis 
in the operation for the hydrocele ; a 
practice now altogether laid afide, even 
where the cyft is much thickened. 



CHAP. 



Ch. XLV. Of dimini/hing Pairt. 437 



G H A P. XLV. 



Of Preventing of Dimini/hing Pain in 
Chirurgical Operations. 



TO be able to alleviate the mifery of 
thofe who are obliged to fubmit to 
dangerous operations, muft afford the 
higheft gratification to every practition- 
er : And as pain is the mofl dreadful 
part of every operation, it neceffarily 
demands our mod ferious attention. 

The pain induced by operations may 
be leffened in different ways : By dimi- 
nifhing the fenfibility of the fyftem ; 
and by comprefling the nerves which 

fupply 



43 $ Of dimlnijhhig Pain Ch. XLV. 

fupply the parts upon which the opera- 
tion is to be performed. 

Narcotics of every kind might be em- 
ployed for the purpofe of lefTening gene- 
ral fenfibility ; but nothing anfwers this 
with fuch certainty and effecT; as opium. 

But as medicines of this kind, when 
given in fuch large dofes as to prevent 
or diminifh pain, are apt to induce fick- 
nefs and vomiting, I feldom venture on 
giving them before an operation. In 
general they prove moft ufeful when 
given immediately after, when they very 
commonly alleviate that pungent fore- 
nefs of which patients at this time ufual- 
ly complain ; and by continuing to give 
them in adequate dofes from time to 
time, we are often enabled to keep the 
patient eafy and comfortable, till relief 
is obtained by the formation of matter, 
or by the removal of that inflammatory 
tenfion which ufually accompanies every 
capital operation : And as this proves 
not only highly comfortable to the pa- 
tient, but tends in the moft effectual 

man- 



PLAT-t; UXXXVl 





Ch. XLv. in Chirurgical Operations. 439 

manner to moderate the febrile fymp- 
toms which commonly take place, it 
ihould never be omitted. 

It has long been known, that the fen- 
fibility of any part may not only be lef- 
fened, but even altogether fufpended, by 
compreffing the nerves which fupply it : 
And accordingly, in amputating limbs, 
patients frequently defire the tourniquet 
to be firmly fcrewed, from finding that 
it tends to diminifh the pain of the ope- 
ration. 

The effect of this, however, being in- 
confiderable, it has lately been propofed 
by Mr James Moore of London, to com- 
prefs the principal nerves fo completely 
as to render the parts beneath altogether 
infenfible. In Plate L^XIII. an inftru- 
ment is delineated, by which this may 
be very effectually done. 

Whether or not it will anfwer with 
eafe and certainty, experience alone mufl 
determine : But, in the mean time, we 
are much indebted to the ingenious au- 
thor, for affording a hint which eventu- 
ally 



44° Of dhninijhing Tain. Ch. XLV, 

ally may tend to mitigate the fufferings 
of thofe whom neceflity obliges to fub- 
mit to chirurgical operations. All that 
this inftrument feems to require in order 
to render it perfect, is the power of 
compreffing the nerves of a limb without 
affecting the veins : for as it is found 
that the nerves muft be compreffed for a 
confiderable time, at leaft an hour, be- 
fore the parts beneath are rendered al- 
together infenfible, the veins could not 
be comprefTed for fiich a length of time 
but with the rilk of burfting. With 
a view to prevent fuch a difagreeable oc- 
currence, Mr Moore propofes that one of 
the veins in the limb fhould be opened. 
But as this might prove hurtful to weak- 
ly patients, where it is often of import- 
ance to guard againft the lofs of blood, 
it would be better to avoid it, by having 
the inftrument formed in fueh manner, 
that it might comprefs the principal nerves 
only, without materially affecting the 
veins. It will not indeed be eafily done, 
as the nerves for the mofl part are at no 

greats 



I' I -ATI. LXXXVtt 




Ch. XLV. in Chirurgical Operations* 441 

great diftance from the veins: But the 
fame purpofe may perhaps be anfwered 
by compreffing the arteries which fupply ] 
the limb for a minute or two before any 
prefTure is applied to the veins ; by 
which the latter may be previoufly empt 
tied. 



Vol. VI* Ff CHAP, 



442 General Obfervations Ch. XLVF. 



CHAP. XLVL 
Of Midwifery. 



SECTION I. 

General Obfervations on Midwifery. 

MIDWIFERY being now confidered 
as a diftinct branch of practice, a 
minute account of it will not be expected 
in a Syftem of Surgery. For more parti- 
cular information, thofe authors who have 
wrote upon the fubject may be confulted : 
but I have judged it proper to delineate 
the inftruments ufually employed in 

Midwifery j 



(Sect. I. on Midwifery. 443 

Midwifery ; and to defcribe two opera- 
tions, which, although immediately con- 
nected with this branch, are yet more fre- 
quently performed by the furgeon than 
the accoucheur ; namely, the Caefarean 
operation, and the divifion of the fym- 
phyfis pubis; 

A great variety of inflruments have 
been invented by practitioners in mid- 
wifery ; almoft every publication, in- 
deed, upon this fubjeclj announces fomei 
invention of this kind. • It is only thofe 
inflruments, however, which experience 
has mown to be ufefulj that we mean to 
defcribe : Thefe are not numerous ; they 
are all delineated in Plates LXXXIX. 
XC. XCL XCII. and XGII1. with the for- 
ceps in Plate LXXXIX, fig. 2, We lay 
hold of the head of the child when the 
mother is much enfeebled, and the con- 
traction of the uterus not fufficient to ex- 
pel the child in the ufual way : And when 
delivery cannot be effected even in this 
manner, or by turning the child, and 
bringing it away by the feet, as fomer 
Ff 2 timef 



444 General Obfervations Ch. XLVT. 

times happens from the pelvis being much 
diftorted, we employ the crotchet repre- 
fented in Plate XCr fig. i . for bringing 
the child away piece-meal, after leffening 
the fize of the head by an opening made 
in the fkull for difcharging the brain with 
the fcilTars reprefented in fig. l, of the 
fame Plate. 

The necemty, however, of ufing any 
of thefe inftruments I believe to be a rare 
Occurrence : they are indeed frequently 
employed ; but this proceeds in a great 
xneafure from impatience on the part 
of practitioners, who often force the de- 
livery of the child, when Nature, if left 
to herfelf, would effect it in a much more 
eafy manner. This fact is fo certainly 
well-founded, and is of fuch general im- 
portance, that practitioners of every de- 
fcription, and more efpecially thofe who 
are newly entering on bufinefs, mould 
never lofe fight of it. By not meeting 
with that attention which it merits, 
both the forceps and crotchet are daily 
employed with too much freedom, to 

the 



* 



PLA-IX XXXXV11L 




Sect. I. on Midwifery. 445 

the difgrace of the 'art, and often with 
irreparable injury both to the mother and 
child. 

In fome cafes it happens, that delivery 
cannot be effected even with the amftance 
of thefe inftruments, owing to the brim 
of the pelvis being fo narrow that it will 
not allow any part of the child to pafs. In 
fuch circumftances, the Caefarean Section, 
as it is termed, ufed formerly to be prac- 
tifed ; but the danger attending that ope- 
ration being fo great, that the mother was 
feldom faved by it, Mr Sigault of Paris, 
about ten years ago, propofed the divifion 
of the fymphafis pubis, for the purpofe of 
increafing the diameter of the pelvis, and 
for extracting the child in the ufual way, 
by the vagina. 



* f 3 SEC« 



44^ Of the Cafarean Operation. Ch.XLVL 



SECTION II. 



Of the Cafarean Operation. 



THIS operation may become necefiary, 
as we have feen in the laft Section, 
by the brim of the pelvis being fo nar- 
row that it will not allow the child to 
pafs ; and it may alfo become proper 
where the child has been forced into 
the cavity of the abdomen by a rupture 
in the uterus, as fometimes happens from 
the uterus contracting with too much 
force before the os tincse is fufficiently 
dilated. 

The Caefarean fedion may be perform- 
ed, either with a view to fave both the mo- 
ther and child, when it is found that the 
child cannot be extracted in any other 
manner ; to fave the mother only when 
we know that the child is dead j or to 



Sect. II. Of the Cefarean Operation. 447 

iave the child immediately after the death 
of the mother. 

As there are few inftances of the mo- 
ther being faved by this operation, fome 
have advifed that it fhould never be per- 
formed till after the death of the mo- 
ther. I am clearly of opinion that an 
operation attended with fo much hazard 
mould never be advifed as long as there 
is the leaft reafon to hope that delivery 
may be effected in any other manner : 
but I alfo think, that it is the duty of 
every practitioner to propofe it when 
this cannot be accomplifhed ; for it is 
furely better to afford the fmall chance 
to the mother ' which accrues from it, 
than to leave her to a certain proipect 
of death ; while by the fame means we 
may be enabled to fave the child, which 
otherwife would be deftroyed. None 
will helitate in advifing it after the 
death of the mother, when the child is 
found to be living. The following is 
the method of performing it. 

The patient fhould be placed upon a 
F f 4 table 



44-S Of the Cafarean Operation. Gh.XLVL 

table of the ufual height, and laid upon 
her back, her hands and legs being pro- 
perly fecured by affiftants ; her head 
fhould be moderately elevated with pil- 
lows, and her thighs fbmewhat raifed, in 
order to relax the abdominal mufcles. 
The operator Handing on one fide of the 
table, is with a common round-edged 
fcalpel to make an incifion, fix inches in 
length, through the fkin and cellular 
Jubilance, on one fide of the abdomen : 
The cut fhould commence two inches 
above the umbilicus on the outer edge 
of the rectus mufcle, and from thence 
fhould be carried in' a perpendicular di- 
rection downwards. The uterus is now 
to be laid bare, by carrying the incifion 
through the tendinous parts of the ab- 
dominal mufcles and peritonaeum ; and 
this being done, an opening of the fame 
length muft be made in the uterus itfelf. 
The eafiefl method of efFecting this is, 
to make a fmall opening with the fcal- 
pel, fufficient to admit the finger, which 
Terves as a conductor to a probe-pointed 

bifloury, 



f'l.ATT;. 1.\\\i\ 




Sedl. II. Of the Ccfarean Operation. 449 

biftoury, with which the remaining part 
of the incifion fhould be finiihed. I may 
alfo remark, that the biftoury inferted 
upon the finger, at an opening made for 
the purpofe, is the beft method of dividing 
the peritonaeum and tendinous aponeu- 
rofis of the abdominal mufcles. 

If any large blood- vefTel is cut in di- 
viding either the external parts or the 
uterus, it fhould be immediately tied 
with a ligature of a fufficient length to 
hang out at the wound. The child muft 
now be taken out ; the placenta, and any 
efFufed blood that may have efc^ped du- 
ring the operation, being alfo removed ; 
and the inteftines, if they have protru- 
ded, being replaced ; the external open- 
ing fhould be fecured with three or four 
futures, in the manner we have advifed 
in Chapter XXXVI. Seel. XII. § 3. 

The wound being covered with a pled- 
git of any emollient ointment, the abdo- 
men fhould be fupported with feveral 
jurns of a broad flannel roller ; when the 

patient 



45° Of the Cafarean Operation. Ch.XLVI, 

patient mould be carried to bed, and 
ftrictly enjoined to avoid fpeaking and 
every kind of exertion. 

Various caufes concur to render this 
a very dangerous operation : Of thefe, 
the extenfive expofure of the abdominal 
vifcera, and hemorrhagies from the ute- 
rus, are the moft material. Any pro- 
trufion, therefore, which occurs of the 
bowels ihould be immediately replaced, 
and no velTel of any importance that 
may be cut in the divifion of the uterus 
ihould be left untied : It is not advifed 
by writers upon this fubject, but I fee no 
harm that can enfue from it. If the li- 
gatures are applied with the tenaculum, 
they will foon feparate ; and by hanging 
out at the external wound, they may at 
eny time be pulled away. It may be 
remarked, that it is internal hemorrhagies 
only that we have to dread, I mean fuch 
as occur from the vefTels of the uterus : 
for, by carrying the incifion on the out- 
er edge of the rectus mufcle, we avoid 
$ie epigaftric artery ; the only vefTel of 

im* 



&ect. II. Of the Cefarean Operation. 45 r 

importance that runs any rifk of being 
hurt in the divifion of the teguments and 
mufcles. 

In order to avoid the rifk of hemor- 
rhagies from the uterus, fome have ad- 
vifed the incifion never to be made at 
that part where the placenta adheres ; 
while, by others, we are directed to 
make the opening into the uterus exact- 
ly in a longitudinal direction, by which 
we are told that the principal vefiels 
with which it is fupplied will moft readi- 
ly be avoided. No advantage, however, 
is derived from this in practice : For the 
incifion in the uterus muft correfpond 
exactly with the external incifion ; which 
cannot with propriety be made in any 
other direction than the one we have 
mentioned. Befides, it would often be 
impoflible to diftinguifh the part at which 
the placenta adheres ; nor is there much 
ground to fuppofe that the hemorrhagy 
from the uterus depends fo much upon 
the direction as on the extent of the in- 
cifion j and it ought not to be lefs than 

fix 



45 2 Of the Cafarean Operation. Ch.XLVI, 

fix inches in length, as the child could not 
be extracted with freedom at a fmaller o- 
pening. It is fcarcely neceffary to remark, 
that the child and placenta mould be 
removed as foon after the incifion is 
made in the uterus as poflible : It is thus 
allowed to contract, which it does in- 
ftantaneoufly with great force ; by which 
the hemorrhagy is more readily Hopped 
than by any means we could employ 
for it. 

By others, we are advifed to leave a 
large opening at the under part of the 
external incifion, in order to give vent 
to any erfufion of blood that may hap- 
pen. No advantage, however, is gained 
by this, as the incifion in the uterus, al- 
though oppofite to the external opening 
at firft, very foon falls beneath it when 
this vifcus contracts ; by which any blood 
that is difcharged falls into the bottom 
of the abdomen where it coagulates, and 
thus cannot be difcharged at the wound. 
And as it is of importance to prevent 
£he air as much as poflible from finding 

accefs 



Ml, AT!, v ' ' 




Seel. II. Of the Cafarean Operation, 453 

accefs to the abdomen, the external cut 
mould be quickly and entirely Ihut by 
as many futures as the length of it re- 
quires. The moll effectual method with 
which I am acquainted of preventing 
hemorrhagies is, the tying of any large 
veffels in the manner we have mention- 
ed ; keeping the patient cool and free 
from pain, by regulating the air of the 
apartment to a proper temperature, and 
adminiftering opiates ; and by preventing, 
as we have obferved above, every kind of 
bodily exertion. 



SECTION III. 

Of the Divifion of the Symphyjis Pubis. 

IT has been long known, that the bones 
of the female pelvis are connected in 
fuch a manner, that during the latter 
months of pregnancy, and especially du- 
ring 



4^4 fytbe Dfojfion of the Ch.XL,V$ 

j-ing labour, they are feparated in fomc 
degree from each other ; by which the 
pafTage of the child is rendered much 
eafier than it otherwife would be. It 
was a knowledge of this fact, and the 
great danger attending the Csefarean ope- 
ration, which firfl fuggefted the idea of 
dividing the bones of the pubis at their 
junction with each other in cafes of nar- 
row pelvis. It was propofed upwards of 
two hundred years ago, by a French fur- 
geon of the name of Pineau ; but Mr 
Sigault of Paris was the firft who had 
the merit of putting it in practice, in the 
year 1777. 

The operation is eafily performed. 
The patient muft be laid upon her back 
on a table of a convenient height ; the 
pelvis mould be elevated with two or 
three pillows put beneath it, and the legs 
and arms fhould be fecured by affiftants. 
When in this fituation, the bladder 
mould be emptied by the introduction 
of a catheter, which mould be retained 
in the urethra by one of the affiftants 

till 



Secft. III. Symphyfis Pubis. 455: 

till the divifion of the bones is com- 
pleted. 

After fhaving the pubis, the operator 
(landing on one fide of the patient, 
fhould with a longitudinal incifion di- 
vide the fkin and cellular fubflance co- 
vering the pubes at their fymphyfis : The 
cut mould commence at the upper edge 
of thefe bones, and be continued nearly, 
but not entirely, along their whole 
breadth : On the bones being, laid bare, 
the cartilage by which they are joined 
mufl be flowly and cautioufly divided ; 
and as it is by no means hard, it is ealily 
done. Both the teguments and carti- 
lage may be divided with a firm round- 
edged fcalpel of the common form, which 
is the only inftrument except the cathe- 
ter that is neceflary in this operation. 
The intention of the catheter is, to point 
out the courfe of the urethra to the ope- 
rator ; for it lies fo contiguous to the 
pubes at their fymphyfis, as to be in 
great danger of being cut, if this pre- 
caution be not attended to j even the 

bladder 



45 6 Of the Divifion of the Ch.XLVL 

bladder itfelf might be injured, were the 
divifion of the cartilage not conducted 
with caution : but with due attention to 
thefe points, and avoiding the total divi- 
fion of the foft parts at the under edge 
of the bones, all rifk of hurting either 
the bladder or urethra may be prevent- 
ed. 

On the divifion of the cartilage being 
completed, the bones recede confider- 
ably from each other. To prevent any 
confequences that might enfue from 
their feparating forcibly and fuddenly, 
the afliftants who have the charge of 
the thighs mould be defired to fupport 
them, particularly towards the end of the 
operation ; and if a fufEcient opening is 
not gained in this manner, the thighs 
may afterwards be flowly and gradually 
feparated. 

The child is now to be delivered in 
the ufual way by the vagina ; and this 
being effected, and the placenta removed, 
the bones fhould be immediately put to- 
gether, and retained as exactly as pofli- 

ble 



Sect. III. Symphyjis Pubis. 457 

ble in their Situation, by the proper ap- 
plication of a flannel or cotton roller 
round the pelvis and thighs ; at the fame 
time that the patient fhould be defired 
to remain as much as poflible in one po- 
fture. The fore does not require any- 
particular attention : in general it heals 
eafily with light mild dremngs ; and for 
the moft part the union of the bones is 
completed in the courfe of the fifth or 
fixth week. The patient, however, mould 
not be allowed to walk, or to put the 
body into any pofture that might effect 
an alteration in the fituation of the bones, 
till nine or ten weeks have elapfed. 

The only objection of importance that 
occurs to this operation is, the fmall 
fpace that is gained by it in that part of 
the pelvis where it is moft required. By 
feparating the offa pubis at their fym- 
phyfis, thefe bones do indeed recede to 
a considerable diftance from each other ; 
for the moft part, the feparation that 
takes place will be at lead two inches in 
length : But this does not increafe the 

Vol. VI. G g narrow 



45 § Of the Divifion of the Ch.XLVl, 

narrow diameter of the pelvis ; that is, 
the bones of the pubis will flill remain 
at nearly the fame diflance from the os 
facrum as before the operation ; and in 
almoft every inftance of difficult labour 
from mal- conformation of the pelvis, we 
find it proceeding entirely from the offa 
pubis and os facrum being too near to 
each other* It may often happen, how- 
ever, that the head of the child may be 
fo fituated, that even this feparation of 
the offa pubis alone may allow it to pafs, 
when otherwise it would have remained 
entirely above the brim of the pelvis j 
and as we do not find that the operation 
is in any refpect hazardous, for in diffe- 
rent inftancas it has been done more 
than once on the fame perfon, it mould 
always be advifed, when we are convin- 
ced that the pelvis is fo narrow that the 
child cannot poffibly pafs through it. 
It fhould always be advifed in preference 
to the Casfarean operation. 

If farther experience fhall mow, that 
in all cafes of narrow pelvis, the child 

may 



rj^\j r.. j\a n 




Se<5l. Ill, Bymphyjis Pubtf, 459 

may be delivered in this manner, it fhould 
even be preferred to the mode of deli- 
vering with the crotchet, which is un- 
doubtedly one of the mod barbarous 
operations in furgery ; for while the very 
intention of it is to deftroy the child, it 
often tears and mangles the mother fo 
much that me never afterwards recovers 
from it. 



G§2 CHAP, 



4<So Of Opening. Ch.XLVII, 



CHAP. XLVIL 



Of Opening Dead Bodies. 



"ITH a view to difcover the feat 
and caufes of difeafes, and at the 
inftance of the civil magiftrate in cafes 
of violent death, furgeons are employed 
to open dead bodies. To do this with 
accuracy, every preternatural appear- 
ance mould be committed to paper. Af- 
ter noting any external marks of difeafe, 
we proceed to examine the ftate of the 
different cavities and of their contents. 
When the diforder has been feated in one 
cavity, we do not open the others ; but 

when 



Ch.XLVII. Dead Bodies. 461 

when they are all to be examined, it is 
proper to begin with the head. 

The body being placed upon a table 
of a convenient height, and the head 
firmly fixed by an' amftant, an incifion 
fhould be made from ear to ear acrofs 
the parietal bones. The fcalp is now. to 
be difTected from the parts beneath 5 and 
one half being turned backward and 
the other over the face, a common am- 
putating faw muft be ufed for dividing 
the cranium : The divifion may be be- 
gun on the os frontis immediately above 
the frontal finufes, and muft afterwards 
be continued backward through the pa- 
rietal bones and os occipitis. The up- 
per part of the fkull is now to be raifed 
with a levator ; by this means the dura 
mater may be freely examined ; and if 
we wifh to go to the depth of the ventri- 
cles only, in order to difcover whether 
any perternatural quantity of ferum be 
collected in them, this may be done 
without removing the brain. 3ut when 
pur object is to examine the ftate of the 
G g 3 brajn 



462 Of Opening Ch.XLVII, 

brain and cerebellum, they muft both be 
removed and examined at leifure. This . 
being done, and all the extravafated 
blood taken off with a fponge, the brain 
and cerebellum muft be replaced with 
the fkull-cap above them. The two por- 
tions of fcalp are now to be drawn over 
the whole, and fecured in their fituation 
by fewing the edges of the cut together 
from one end to the other, either with 
the glover's ftitch, or in any other way 
which the operator may prefer. For 
.this purpofe narrow tape is ufually em- 
ployed,' and a large curved needle with 
a triangular point. 

The cavities of the thorax and abdo- 
men are mod effectually expofed in the 
following manner : Let an incilion be 
made through the common teguments 
from the top of the fternum to the um- 
bilicus, and let it be continued on each 
fide through the abdominal mufcles, 
from the umbilicus to the top of the 
os ileum : The teguments and mufcles 
muft now be dhTected from the thorax^ 

til) 



v±\re. xciu. 




Ch.XLVII. Dead Bodies. 463 

till all the cartilages which connect the 
flernum and ribs are freely laid bare ; 
and being drawn backward, the cartilages 
muft be divided with a ftrong knife as near 
as pofTible to the ribs ; when the dia- 
phragrn being feparated beneath, the 
under part of the flernum and cartilages 
connected with it, being raifed and turn- 
ed upward, the flernum muft either be 
feparated from the clavicles, or cut acrofs 
near to the upper end of it. In this 
manner the contents of tl>e thorax and 
abdomen are brought into view, when 
moft of them may be examined with? 
out being removed ; but when more ac- 
curacy is required than this admits of, 
the whole of them fhould be taken out : 
Or, when a partial examination is only re- 
quired, that portion of them only may 
be removed which we mean to infpecT:. 

To prevent the inconvenience remit- 
ing from the erFufion of much blood and 
excrement, two ftrong ligatures fhould 
be paffed at the diftance of an inch from 
§ach other round the under part of the 
G g 4 alimentary 



464 Of opening Dead Bodies. Ch.XLVfL 

alimentary canal and large contiguous 
blood -veflels, and round the trachea, 
cefophagus, and large blood-vefTels of the 
neck. The parts between the upper and 
under ligatures being divided, the whole 
vifcera of both the cavities may then be 
eafily removed, by directing them from 
the contiguous parts, and raihng them up 
as we go along. 

The neceflary examination being finifh- 
cd, the effufed blood all wafhed off with 
a fponge, and the vifcera replaced, the te- 
guments muft be drawn Over them, and 
ftitched together with as much neatnefs 
as poflible. 

In opening bodies that have died of any 
difeafe, the operator mould be as cautious 
as poflible in avoiding cuts or fcratches of 
his fingers and hands : Various inflances 
have occurred of much diflrefs being in- 
duced ; and in fome cafes, even death has 
enfued, from inattention to this circum- 
Itance, 

CHAR 



fh. XL VIII. Of Embalming. 465 



CHAP. XLVIII. 



Of Embalming. 



N former times, embalming was prac- 
tifed with more care and attention 
than it is now. This was a neceflary con- 
fequence of the deflre which then prevail- 
ed, of preferying dead bodies for ages. 
At prefent it is feldom employed, except 
for the purpofe of preventing bodies 
from putrefying, during the fhort fpace 
which elapfes between the death and 
burial of the perfon ; and not even with 
this view, if the corpfe be not to be kept 
longer than is ufually done in private life. 
The following is the prefent method of 

em- 



466 Of Embalming. Ch.XLVIII, 

embalming. The brain, and all the vifce- 
ra of the thorax and abdomen, being re- 
moved in the manner we have mentioned 
in the laft Chapter, they are all, excepting 
the heart, put into a leaden box with a con- 
siderable quantity of an aromatic antefep- 
tic powder, prepared with myrrh, frank- 
incenfe, cloves, the leaves of lavender, 
rofemary, mint, fage, and other fimilar 
articles ; and to thefe are added a pro- 
portion of any odoriferous oils. The 
blood being removed from the different 
cavities, and the heart replaced, they are 
all filled with the fame kind of powder, 
with a due proportion of odoriferous 
oils or fpirits, and the parts afterwards 
fewed up in the manner we have already 
advifed. By fome, too, the mouth and 
noflrils are (luffed with thefe powders 
and oils ; and incifions are made into all 
the flefhy parts of the body, which are 
alfo fluffed with them, and afterwards 
fewed up : but there is no neceffity for 
this, unlefs the body is to be kept for a 
great length of time, or to be carried to 

a 



CLXLVIII. Of Embalming. 46*7 

a confiderable diflance. In which cafe, 
it is ufual, after fluffing the incifions in 
the manner we have mentioned, to roll 
all the extremities, as well as the trunk 
of the body, firmly up with bandages, 
and to cover the whole with varnifh. 

The body is now to be laid upon a 
Cerecloth of a fufEcient fize, which mufl 
be applied with as much neatnefs as pof. 
fible to the head and every part of the 
body, and mufl either be firmly fecured 
by fewing, or with tapes tied at proper 
diflances. The cerecloth is made of 
linen dipped in a compofition of wax, 
oil, and rofin ; which fhould be of fach 
a confiflence as to be fufficiently pliable, 
without being fo foft as to flick to the 
fingers of thofe who apply it : It may be 
coloured with verdegris, red lead, or 
any other article, according to the fancy 
of the operator. When two cerecloths 
are applied, one above another, they are 
ufually made of different colours. 

The cerecloth being put on, it was 
formerly the cuflom to employ a painter 

to 



468 Of Embalming. Ch. XL VIII. 

to colour the face ; but this is now very 
commonly omitted : the drefs intended 
for the corpfe is immediately put on ; and 
the body is either laid in the coffin, or 
allowed to be expofed, according to cir- 
cumftancfes. 



CHAP, 



I 



Ch. XLIX. Of Bandages. 469 



CHAP. XLIX. 
Of Bandages. 



BANDAGES are employed for vari- 
ous purposes in Surgery ; for the 
retention of dreflings ; for flopping he- 
morrhagies ; for removing deformities ; 
and for effecting the union of divided 
parts. 

As a proper application of bandages 
is an objedl of much importance, it is a 
branch of the art which authors have 
not neglected : Many treatifes have been 
publifhed upon it ; but unfortunately it 
cannot be taught by defcription : Expe- 
rience alone can give an adequate idea 

of 



47C Of Bandages, Ch.XLIX» 

of it ; nor is it poffible to acquire it but 
by much manual practice. Hence, in the 
iUidy of this part of furgery, more ad- 
vantage is to be gained by pradtifing up- 
on a block, than by reading the moft 
elaborate dhTertations. My only inten- 
tion, therefore, at prefent is, to offer a 
few general obfervations upon banda- 
ges. 

i. Bandages mould be formed of fuch 
materials as are fumciently firm for ef- 
fecting the purpofe for which they are 
intended, at the fame time that they may 
fit with eafe upon the parts to which they 
are applied. 

In fome cafes a degree of firmnefs is 
required, which cannot be obtained from 
materials of a foft texture : Of this we 
have examples in the moft part of trufTes 
for herniae, as well as in every bandage 
requiring much elafticity : But for the moft 
part bandages are made of linen, cotton, 
or flannel. Till of late, linen was uni- 
verfally ufed for this purpofe ; but later 

experience 



Ch. XLIX. Of Bandages] 47 1 

experience has fhown, that cotton and 
flannel are preferable. They abforb moi- 
flure more readily, whether it be pro- 
duced by fweat, or as the ordinary dif- 
charge of wounds or fores, at the fame 
time that they are better calculated by 
their elafticity for yielding to the fwell- 
ing which often takes place in luxations, 
fractures, and other injuries for which 
bandages are employed. Flannel was 
firft ufed for this purpofe in the Royal 
Infirmary here, about thirty years ago, 
by Mr James Rae of this place ; and 
fince that period the practice has been 
, generally adopted. The objection made 
to the ufe of flannel for bandages, by 
fome practitioners, of its not being fo 
cleanly as linen, is frivolous : Neither 
of them will be cleanly if they be not 
frequently changed, while either of 
them will be fufEciently fo if this point 
be attended to. 

2. Bandages fhould be applied of a 
degree of tightnefs fufEcient for an- 

fwering 



472 Of Bandages'. Ch. XLIX, 

fwering the purpofe for which they are 
intended, without incurring any rifk of 
their impeding the circulation, or doing 
harm in any other manner. No advan- 
tage will accrue from them, if they be 
not fufficiently tight to fupport the parts 
affected ; while fwelling, inflammation, 
and even gangrene, will be apt to oc- 
cur if they be too tightly applied. 

3. Every bandage fhould be applied 
in fuch a manner, that it may be as eafily 
3 -->ofened, and the parts examined with as 
much accuracy as poffible. Thus in frac- 
tures of the thigh and leg, where the 
limb cannot with propriety be frequent- 
ly raifed, we now prefer univerfally the 
bandage with twelve or eighteen tails to 
the common roller. The former can be 
undone and fixed at pleafure without 
moving the limb, while a roller can nei- 
ther be applied nor removed without 
railing every part of the limb to a con- 
fiderable height. 

4. Bandages fhould always be laid 
afide as foon as the purpofe for which 

they 




E1G-.2 




FIG-. 1 




Ch. XLIX, Of Bandages* 473 

they arc intended is accomplifhed. This 
being obtained, no advantage can accrue 
from them, and they often do harm by 
impeding the growth of the parts upon 
which they are applied* 

5. We have found it necefTary in the 
courfe of this work to mention banda- 
ges for many parts of the body. In 
fpeaking farther of bandages for parti- 
cular parts, we fhall begin with the headj 
and proceed downwards to the trunk of 
the body and extremities. One of the 
beft bandages for all the upper and back 
parts of the headj for the forehead^ earsj 
and temples, is a night-cap, with one 
band to tie it before, and another beneath 
the chin, as is reprefented in Plate XGIV* 
fig. 1. The Couvre-chef of the French^ 
reprefented in fig. 2. is moft frequently 
ufed for thefe parts j but it can neither be 
applied with fuch firmnefs or neatnefs as 
the night-cap. 

For the purpofe of making compre£* 
fion on an}- particular part of the head, 

Vol, VI. H h the 



474 Of fi an <? a g es ' Ch. XLIX* 

the Radiated Bandage, as it is termed, 
may be employed, as is reprefented in 
Plate XCIV. fig. 3. It may alfo be ufed 
for comprefling the temporal artery : but 
for this purpofe, the machine reprefented 
ill Plate VII. fig. 3. anfwers better. 

In longitudinal cuts of the head, the 
Uniting Bandage, as it is termed, may be 
ufed with advantage. It is formed of a 
long roller with two heads, with a flit or 
opening in the middle, as is reprefented 
m Plate XCV. fig. 3. The fides of the 
cut being drawn neatly together, and co- 
vered with a pledgit of any fimple oint- 
ment, the cure is to be effected by means 
of this bandage, applied in the manner re- 
prefented in fig. 6. of the fame Plate. In 
cuts of this defcription, their edges may 
fometimes be retained together with fuffi> 
cient exactnefs by this bandage j and, 
when this can be done, it will always 
be preferred to the mode of doing it by 
futures. 

When it is neceffary to retain dreff- 

ings 



Ch. XLIX. Of Bandages* q.jr 

ings upon the eyes, it has ufually been 
done by placing a comprefs over them, 
and retaining it by feveral turns of a 
long roller, fuch as is reprefented in 
Plate XCV. fig. r. This bandage, when 
employed for one eye, is the Monoculus 
of authors, and it is termed Binoculus 
when applied to both eyes. But as a 
roller pafTed round the head is apt to 
flip, even when applied in the moft exact 
manner, the couvre-chef in Plate XCIV. 
fig. 2. or the night-cap in the fame Plate 
fig. i. are by many preferred for retain- 
ing the compreffes. 

In fractures and cuts of the nofe, th© 
drefhngs are bed retained by a proper 
application of the uniting bandage in 
Plate XCV. fig. 3. and a proper applica- 
tion of the fame bandage anfwers beft in 
longitudinal cuts of either of the lips. 

In fractures of the lower jaw, we em- 
ploy a four-headed roller, fuch as is re- 
prefented in Plate XCV. fig. 4. The 
fpace left entire between the four-heads 
at A, is applied to the chin, the hole in 
the centre of it being meant to receive 
H h 2 the 



476 Of Bandages, Ch. XLlX 

the apex of the chin. The two fuperior 
heads are then carried backwards ; and 
being made to pafs each other at the 
occiput, they are afterwards brought 
forward over the os frontis : they may 
either be fixed there, or again reflect- 
ed back, and fixed with pins on the fides 
or back-parts of the head. The two 
under heads of the roller being reflected 
over the chin, are then to be turned up- 
wards, and either tied or pinned on the 
top of the head; or before fixing them, 
they may be made to pafs each other 
two or three times. Various other ban- 
dages are defcribed by authors for the 
head ; but thofe we have mentioned,* 
with a proper application of the common 
roller, Plate XCV. fig. 1. for particular 
purpofes, are all that can be ever re- 
quired. 

6. In Plate XXIII. fig. 1. an inftru- 
ment is delineated for one of the moll 
material operations upon the neck, Bron- 
chotomy ; and in Plate LXVI. fig. 1, 
another is reprefented for the wry neck :. 

A 



K. \('\ 











1 



Ch. XLIX. Of Bandages. 477 

A common roller may be made to an- 
fwer every other purpofe that can be re- 
quired of a bandage in any part of the 
neck. 

7. A variety of bandages are ufed for 
affections of the moulders and contiguous 
parts, particularly for fractures of the 
fcapula, and fractures and luxations of 
the clavicle. In fractures of the fcapu- 
la, a proper application of a long roller 
may, in molt inftances, prove ufeful ; but 
in Chapter XXXIX. Section V. we have 
mown, that no utility is derived from 
bandages in fractures of the clavicles ; 
They cannot be applied with fuch tight- 
nefs as to comprefs the fractured bone 
without impeding refpiration ; and be- 
fides, we do not find that they are neeeC- 
fary, when the arm of the affected fide 
is properly fupported by the fling, Plate 
LXXXI. 

8. The moft ufeful of all bandages for 
the thorax and abdomen, at lead for the 
retention of dreffings on any of thofe 
parts, is that which we ufually term the 

H h 3 Napkin 



478 Of Bandages. Ch.-XLIX. 

Napkin and Scapulary, reprefented in 
Plate XCVL fig. i. That part of it 
•which goes round the body A, is termed 
the Napkin. When it is applied for ma- 
king prefiure upon a fractured rib, it 
mould be in the form of a roller, and 
{hould pafs two or three times round the 
body ; when it is only ufed for retaining 
dreffings, it mould not go more than 
once round: It mould be fix or feven 
inches broad for an adult ; and it mould 
]be fecured by pieces of tape, tying it at 
each end inftead of pins. The Scapulary 
BB, confifls of a flip of linen, cotton, or 
flannel, about three inches broad, and of 
a length fuflicient to reach from the up- 
per part of the napkin behind, to pafs 
over the moulders and be pinned to it 
before : It is fometimes made with a hole 
in the centre of it for pafTing over the 
head ; but it anfwers better to divide the 
anterior end of it by a longitudinal flit 
into two, and, in applying it, to make 
one of thefe flips pafs on each fide of 
the head, 

Thiy 



'.'>! 








•Cli. XLIX. Of Bandages, 479 

This bandage anfwers the purpofe bet- 
ter than any other, for making premire on 
the parts at which the vifcera protrude, 
in cafes of umbilical and ventral hernix. 
As in fuch cafes it is a point of much im- 
portance to have the bandage firmly fixed, 
we not only employ the fcapulary for pre- 
venting it from flipping down, but a ftrap 
connected with it behind is paffed between 
the thighs, and pinned to at before, to pre- 
vent it from flipping up, 
• In Plate XXIL fig. 2. a bandage is re- 
prefented for comprefling the abdomen in 
the operation of tapping; and in Plate VIII. 
different bandages are delineated, or Truf- 
fes, as they are termed, for the retention 
of the protruded vifcera in cafes of her- 
niae. 

9. As it is of much importance in va- 
rious difeafes, as well as in feveral ope- 
rations, to have the fcrotum properly fup- 
ported, I have delineated fome bandages 
for this purpofe in Plate XCVII. The 
bed bandage for the penis is a pouch, or 
jb.ag of linen or cotton, to be fixed by^ 
Hh 4 a 



48 o Of Bandages. Ch. XLIX, 

a roller, or two pieces of tape paffed 
round the body. 

Tlie T-bandage, as it is commonly 
termed, Plate XCVI. figures 3. and 4. is 
ufually employed for the retention of 
dreffings in affections of the anus and pe- 
rineum, as well as in fome diforders 
of the fcrotum ; but in the laft, one or 
Other of the fufpenfory bandages, repre- 
fented in Plate XCVII. will for the moft 
part be found preferable. 

1 o. In compound fractures of the arm, 
fore-arm, or hand, where motion of the 
limb would prove hurtful, the twelve or 
eighteen-tailed bandage is equally proper 
as in ftinilar affections of the lower extre- 
mities. ; but in fimple fractures, as well as 
in almoft every other affection of thefe 
parts, we prefer a proper application of the 
roller. 

1 1. We advifed the uniting bandage for 
longitudinal cuts in the head ; it anfwers 
equally well in wounds of a hjnilar nature 
in every part of the extremities, as is re- 
prefented in Plate XCV. fig. 6. 

EXPL4- 



I 



'Explanation of the Plates, 48 1 



EXPLANATION of the PLATES. 



Plate LXX. 

[Oppofite to page 86.] 

Fig. I. A fplint of timber for a frac- 
tured leg, AA. Two loops for retaining 
leather ftraps, as reprefented in the front 
view of the fame fplint in fig. 2. CC. B, 
an opening for receiving the external 
maleolus, when the leg is placed upon the 
outfide. 

Figures 3. 4. 5. and 6. are perhaps the 
beft fplints hitherto difcovered for frac- 
tures of any of the extremities. They 
may be made of different forms, but 
one or other of thefe will anfwer almoft 
for any purpofe : They are made by glu- 
ing 



482 Explanation of the Platesl 

ing a piece of thin timber, about the 
tenth part of an inch in thicknefs, upon 
leather. The timber is afterwards cut 
through to the leather, either with a 
fine faw or a knife fet to a proper depth, 
in the manner reprefented in the figures. 

Thefe fplints are preferable to thofe 
made of pafteboard ; for while they are 
longitudinally perfectly firm, they are 
tranfverfely fufficiently flexible for plying 
to the form of the limb. For the me- 
thod of ufing them, we muft refer to 
Sections IX. X. XI. and XII. of Chapter 
XXXIX. 

Splints made in this manner have long 
been ufed by individuals ; but Mr Gooch 
was the firfl who gave any defcription of 
fhem. 

Plate LXXI. 

£Oppofite to page 96J. 

As the fplints ufed by Mr William 
Sharpe are Hill preferred by fome prac- 
titioners, I have given a reprefentation of 
them in this Plate. 

Thefe fplints, figures 3. and 4. are 

formed 



Explanation of the Plates, 483 

formed of ftrong pafteboard made with 
glue ; they are fixed upon a fractured 
leg by three ftraps which furround the 
whole. 

Fig. 4. Reprefents an under fplint of 
an irregular form, fuitable to that part 
of the leg it is meant to cover : It is a 
little convex externally, and concave in- 
ternally. The length for a middle-fized 
man, eighteen inches from E to E ; the 
width, two inches and three quarters at 
the ftrap near the knee, and two inches 
and a quarter at both the other ftraps. I 

D F D F D F, three leather ftraps from 
fifteen to twenty inches long, and one 
inch wide, having two rows of holes fo 
placed, that every hole in each row may 
be oppofite to a fpace in the other. Thefe 
muft be fewed faft to the middle and 
outride of the under fplint. The por- 
tions of ftraps DDD, on the anterior 
part of the fplint, muft be fhorter than 
thofe on the pofterior, FFF, which are 
to furround the more mufcular part of 
the leg. 



4$4 Explanation of the Plates. 

G, A part to fupport the foot from the 
point E to the heel H, five inches long at 
an angle of fixty degrees. 

C, The foot ftrap, twelve inches long, 
fewed to the bottom of the under fplint, 
within two inches of the point, to pafs 
under the heel, and through the leather 
loop B on the upper fplint, to the loweft 
pin A. 

I> An irregular oval hole, two inches 
long, and almoft one wide in the loweft 
part, but decreafing upwards, to receive 
the maleolus externus, or lower extremity 
of the fibula. 

Fig. 2. Reprefents the leg raifed up, to 
fhow the fituation of the under fplint, 
when properly applied. 

Fig. 3. The upper fplint. AAA^ The 
pins upon which the flraps of the un- 
der fplint are to be fixed, by means of 
the holes DD D 9 FFF. B, The leather 
loop for receiving the foot-ftrap C, in 

pig, 1. Reprefents a fractured leg 

when 



Explanation of the Plates. 485 

when laid within the fplints, having the 
foot of a flocking and a fhoe upon it. 

Plate LXXII. 

[Oppofite to page 100.] 

In this plate I have delineated the in- 
ftruments recommended by the late Mr 
Gooch, for preferving a fractured thigh 
and leg in a ftate of extcnfion, as is men- 
tioned more particularly in page , and 
which I fhall defcribe in his own words. 

Fig. 1. A machine for extending a 
fractured leg. The tranfom to which 
the fole is fecured, is made to be open- 
ed and fixed by a pin ; and the machine 
may occafionally be made wider, as ap- 
pears by other holes in the tranfom ; 
about which, on each fide of the fole, 
fillets are to be tied, coming from a de- 
mity piece quilted for eafe, and laced 
round the heel and inftep, to make the ex- 
tenfion upon the working of the fcrews ; 
but buff leather may poflibly anfwer bet- 
ter for protecting the parts even than de- 
mi ty. 

Fig. 



486 Explanation of the Plates. 

Fig. 2. Shows the machine, and one of 
the fplints in Plate LXX. together upon 
the limb. 

Fig. 3. The longitudinal parts of the 
machine for the thigh are defigned to 
move upon the circular plates ; by which 
means it may be accommodated to limbs 
of different fizes : and as there is a pin at 
each end of the circular plates, if the limb 1 
happens to be larger than ordinary, ftraps' 
of leather may be added. 

Fig. 4. Shows the machine with the 
cafe upon the thigh. 

Fig. 5. The key to work the fcrews„ 
There mould be two fuch keys, that the 
machine may occafionally be wrought oil 
both fides at the fame time. 

Plate LXXIIL 

[Oppofite to page 109.3 

In page 109, we obferved, that fome 
improvements had been made by Dr Ait- 
ken upon Mr Gooch's inilruments, repre- 
fented in the preceding plate, for extend- 
ing fractured limbs : In this plate I have 
given a reprefentation of them. 

Fig.- 



"Explanation of the Plates* 487 

Fig. 1. Reprefents a machine for keep- 
ing the fragments of the thigh-bone infitu 
after fetting, whether the fracture is fimple 
or compound, on the neck or body of this 
bone. AAA) the upper circular which 
applies round the pelvis •, like the top-band 
of a pair of breeches. It refts on the fame 
parts, and is fixed or buttoned in the fame 
manner, by the ftuds and correfponding 
holes, H. 

BB y Two foft-ftuffed ftraps, fixed to 
the back-part of this circular, of fuch 
length as to pafs between the thighs from 
behind forward, to tie round the fore- 
part of the- fame circular, by means of 
their forked extremities CC, Thefe ef- 
fectually fecure the circular from moving 
upward. There are two obfcure joints, 
KK, in the back part of this circular, to 
facilitate its application ; but it applies 
readily enough without them. 

DD, The lower circular which fixes a- 
bove the knee at the gartering-place. 

EEE, Three graduating fteel fplints 

which 



4$ 8 Explanation of the Platei* 

which extend from the one circular* to 
the other : Their upper extremities are fix- 
ed to the upper circular by vertible flat- 
headed ftuds, fimilar to thofe at FF t their 
lower extremities pafs through the iron 
fcrew- plates G, firmly rivetted to the 
lower circular. The fplints are provided 
with a number of impreflions or holes, 
in which the fcrew -nails which pais 
through the plates are fixed. By pulh* 
ing the fplints from below upward, the 
diftance between the circulars is in-* 
creafed ; and by turning the fcrew-nails, 
it is maintained : confequently, that part 
of the thigh included between the cir- 
culars can be kept extended at pleafure* 
The fplints here are fixed for the right 
thigh ; the pricked lines on the other 
fide, fhow how they may be accommo 
dated for the left one, or for both at the 
fame time. 

The largeft circular AAA^ ronfifts of 
a piece of thick faddle-leather ; all except 
its perforated part, and about a quar- 
ter of an inch on each edge, is covered 

on 



Explanation of the Plates* 489 

On the infide with a flexible thin iron 
plate, fuch as is fometimes ufed by tin- 
plate workers : Over this it is lined with 
the fofteft buff, or fhamoy leather, be- 
tween which and the plate a thin layer 
of hair or wool is interpofed : The lining 
ought to project on both fides half an 
inch or more, to prevent it in any de- 
gree from prefling on the fkin. 

The fmall circular D D, or inferior 
fixed point, is exactly fimilar to the 
large one in ftructure, the tin-plate ex- 
cepted ; which, on account of its fmaller 
diameter, was found to be unnecefTary. 

The breadth of the upper circular, 
when extended for an adult, may be from 
three to four inches : That of the under 
circular fhould be in the fame propor- 
tion. 

The graduating fteel fplints, EEE y 
muft be fufficiently long to extend from 
the upper circular to the lower, and to 
project over it about a hand-breadth : 
They require to be about four or five 

Vol. VI. I i eighth- 



490 Explanation of the Platei. 

eighth-parts of an inch broad, and about 
one eighth -part of an inch thick. 

Fig. 2. A machine conftructed on the 
fame principle with fig. I. for the reten- 
tion of a fractured leg. 

A A, A circular, which applies below 
the knee-joint. 

B By Another, which fixes at the an- 
kles. 

CCC, The graduating fplints fimilar to 
thofe of the thigh-machine, both in con- 
struction and action. 

Fig. 3* A fracture-box mentioned in 
page 150, as the invention of Mr James 
Rae Surgeon of this place, improved by 
Mr John Rae his fon. 

A, The fole or bafe, which fhould be a 
firm deal at leafl an inch and half thick. 
B B, the two ends which fupport the 
fide beams CCCC. D D, Brafs hinges, 
which admit of the ends folding down fo 
as to render the machine more portable 
than it otherwife would be. L Z, two 
parallel grooves for receiving two pro- 
jecting parts of the correfponding end 

of 



Explanation of the P lutes, 491 

faf the machine, by which the fame in- 
ftrument may be extended or fhortened £0 
as to fit any length of member. E E E E y 
Two lateral beams, which by the holes 
in their extremities will ferve for any 
length to which the inftrument may 
be extended : And by the pin at each 
end palling through them at the holes 
in the end beams, any one of the fides, 
or both of them, may be raifed at plea- 
fure. 

GG GG, &c. Twelve or fourteen buc- 
kles on each fide of the machine, with 
correfponding pieces of girth two inches 
broad, on which the member is fupport- 
ed by buckling them exactly to the 
form of the Hmb'. HI, HI; Two (traps, 
with correfponding buckles for fixing 
the bafe of the machine to the bed. The 
limb is fixed to the machine by two 
ftraps and buckles, one fixed at each end. 
The advantages of this inftrument are, 
that in compound fractures the fores 
be infpected and (Jrefled without de- 
ranging or moving any part of the limb, 
tki by 



49* Explanation of the Plates. 

by removing fiich of the ftraps as arc 
neceflary for bringing the fores into 
view. Inftead of a twelve or eighteen- 
tailed bandage of the common form, fe- 
parate pieces of flannel mould be ufed ; 
fo that fuch of thofe as are wet with the 
difcharge can be eafily moved without 
touching the reft. 

In this manner the limb may be re- 
gularly dreffed without being moved till 
the cure is completed, while the limb 
may be raifed to any angle, by height- 
ening one or other of the ends of the late- 
ral beams by means of the holes and 
pins at each end. 

Plate LXXIV. 

[Oppofite to page 122]. 

Fig. 1 . A fractured limb drefTed with 
an eighteen-tailed bandage, and laid up- 
on the outfide with the knee bent, in the 
manner recommended by Mr Pott. 

Fig. 2. A fractured limb with an 
eighteen-tailed bandage, and one of the 
flexible fnlints in Plate LXX. There 

is 



Explanation of the Plates, 493 

is alfo placed beneath the limb a firm 
unyielding fplint, fuch as is reprefented 
in the fame Plate, fig. 2. 

Plate LXXV. 

[Oppofite to page 129.] 

Fig. I. A machine mentioned in page 
117. for retaining the different parts of 
a fractured patella. 

A, A ftrap to be fixed by means of 
the buckle at one end on the upper part 
of the leg immediately below the knee. 
2?, A fimilar ftrap to be fixed above the 
knee. 

Fig. 2. A back view of the fame ma- 
chine. F, A femilunar comprefs of cork 
covered with fhamoy leather, to be pla- 
ced immediately above the upper part of 
the patella. A, A fimilar comprefs for fup- 
porting the inferior part of the bone. 

Thefe compreffes being properly pla- 
ced, they may be drawn to any degree 
of tightnefs by means of the ftraps and 
buckles CD E. 

Fig. 3. A limb with a fractured patel- 
I13 la, 



494 Explanation of the Plaks. 

la, and the bandage fig. i . applied to it. 
In this figure the (trap, H, is added to it : 
being fixed to the point of the fhoe, and 
Connected with one of the buckles above 
the knee, the limb is thereby kept ex- 
tended ; by which there is no rifk of the 
fractured parts of the patella being for- 
cibly pulled from each other, as would 
neceffarily happen if the limb fhould be 
Suddenly bent before the cure be com- 
pleted. 

Pute LXXVI. 

[Oppofite to page 140.] 

Fig. I. This reprefents the Ambe of 
Hippocrates, for the reduction of luxa- 
tions of the humerus: it confifls of a 
fulcrum and moveable lever. As it is 
ftill ufed by fome practitioners, I judged 
it proper to mention it ; but we have 
elfe where had occafion to remark, that 
it is a dangerous inftrument, and ought 
never to be employed. My reafons for 
jth inking fo are enumerated in Chapter 
XL. Section IX. 

?%! 



Explanation of the Plates. 495 

I 

Fig. 2. Mr Petit' s inftrument for redu- 
cing luxations of the humerus. A A t 
Two arms or horns, by which the fea- 
pula is kept firm during the extenfion. 
B B, The other end of the inftrument 
reding upon the ground ; C, the pullies ; 
Z), ropes, by winding up which with the 
handle E the limb may be flowly and 
gradually extended to any neceflary de- 
gree. 

Fig. 3. A C, an opening through which 
the arm is pafled ; F F, two apertures 
for receiving the ends A A of the in- 
ftrument fig. 2. This being made of 
firm leather, the. inftrument is thereby 
prevented from fretting or galling the 
ikin, 

Plate LXXVII. 

[Oppofite to page 148]. 

Fig. 1. The ambe of Hippocrates, re- 
prefented by itfelf in the preceding Plate 
is here applied, and ready to be ufed. 

Fig. 2. Pullies for extending diflocated 
bones, as mentioned in page 231. 

I i 4 Fig, 



49 6" Explanation of the Plates. 

Fig. 3. This is a very ufeful part of 
the apparatus for extending diflocated 
limbs : It is formed of thick fhamoy or 
buff leather. By tying it firmly round 
the limb with the broad ftraps at each 
end, a very confiderable force may be 
applied by affiftants pulling the ropes or 
ftraps paffed over the hooks : it anfwers 
the purpofe both more eaiily and more 
effectually than the common method of 
extending the limb with towels. 

Plate LXXVIII, 

[Oppofite to page 236.] 

In this Plate I have .delineated one of 
the beft inftruments hitherto known fof 
.diilocations of the moulders, when more 
than ordinary force is required. It is 
the invention of the late Mr Freke of 
London. 

As inftruments of this kind require 
to be very portable, Mr Freke has paid 
particular attention to this circumftance. 
The box, fig. 5. contains the whole ap- 
paratus ; 



Explanation of the Plates. 497 

paratus : when fhut, it is only one foot 
eight inches long, nine inches broad, and 
three inches and a quarter deep. Fig. 
4. reprefents the inftrument open, the 
two fides of the box being firmly fixed 
together by brafs hinges at C, and with 
too hooks and eyes on the other fide of 
the box. When one end of it is fixed on 
the ground, the other ftands high enough 
to become a fulcrum or fupport for the 
lever B i?, which is fixed on the roller 
£ by a large wood fcrew, which turning 
fideways, as well as with the roller, it 
obtains a circumrotatory motion, fo that 
it may ferve to reduce a luxation either 
backward, forward, or downward. 

The roller on which the lever is fixed 
is jufl the diameter of the depth of one 
of the boxes, into which are driven two 
iron pins, the ends of which are received 
by the two fides of the box, which are 
an inch thick. 

The lever is two feet four inches long, 
and is cut and joined again by two hinges 

at 



498 Explanation of the Plates'. 

at C, to fold up fo as to be contained in 
the box : on the back-fide of it is a hook 
to keep it ftrait j the other end of it is 
to hang over the roller an inch and a 
half, which is to be excavated and co- 
vered with buff-leather for the more 
eafy reception of the head of the os hu- 
meri. 

The iron roller E has two holes thro* 
it for receiving two cords from a brace 
fig. 3. fixed on the lower head of the. 
os humeri, for on no other part of the 
arm above the cubit can a bandage for 
this purpofe be ufeful ; for if the furgeon 
applies it on the mufcular part of the 
arm, it never fails flipping down to the 
joint before the limb can be extended. 

The iron roller E has a fquare end, on 
which is fixed a wheel Z>, notched round, 
which works as a rotchet on a fpring 
Jcetch under the lever ; by which it is 
flopped as it is wound up with a winch, 
fo that at pleafure it may be let loofe by 
{lifcharging the ketch. 

The brace, fig. 3. confifts of a large 

piece 



Explanation of the Plates. 499 

piece of buff-leather large enough to em- 
brace the arm, fewed on two pieces of 
ftrong iron -curved plates rivetted to- 
gether, one of them having an eye at 
each end to fatten two cords in : the 
other is bent at the ends into two hooks, 
which are to receive the cords after 
they have crofTed the arm above. 

In order to keep the patient fteady in 
his chair, and to prevent the fcapula 
from riling on deprefling the lever, after 
the limb is drawn forward by the winch, 
there muft be fixed over the ftioulder a 
girth with two hooks at the end of it, 
as is reprefented in fig. 2. The girth 
fhould be long enough to reach the 
ground on the other fide, where it muft 
be hooked into the ring J5, fcrewed into 
the floor for that purpofe, as in fig. 1. 

Plate LXXIX. 

[Oppofite to page 248.] 

In this Plate I have delineated an in- 
ftrument mentioned in Chapter XLI. for 

the 



jroo Explanation of the Plates. 

the purpofe of removing contraction* 
of the ham- firings or flexor tendons of 
the leg. 

Fig. i. A front view of the inftrument: 
AA, two curved fteel plates, connected 
together by a firm fteel fplint Z), in fig. 
2. One of thefe is to be applied to the 
back part of the thigh, and the other to 
the upper and back part of the leg ; while 
by means of the leather ftraps E E, fuch 
a degree of prefTure is made as the patient 
is able to bear. 

B B, fig. i . Is a foft cufhion of quilted 
cotton for furrounding the limb to pre- 
vent the leather ftraps from fretting it. 
The curved plates A A fhould for the 
fame purpofe be lined with fhamoy. 

Fig. 2. A back view of the fame in- 
ilrument. 

Fig. 3. A limb with the inftrument 
applied on it. 

Plate LXXX. 

[Oppofite to page 260.3 

I have here delineated a fracture box, 

mentioned 



Explanation of the Plates, 501 

mentioned in page 126. It is formed 
upon the fame principle, but fomewhat 
more fimple in the conftruction than 
Mr Rae's in Plate LXXIII. fig. 3. 

Fig. I. A A, The bafe or bottom of 
the inftrument, formed of deal an inch 
and half thick. BB t Two ends ruing 
from the bafe, and terminating in the 
pillars CCCC. D Z), An excavated move- 
able piece of timber for fupporting the 
fractured limb. This moveable part of 
the inftrument may be raifed and fup- 
ported at any height by the pins E E 
pafling through the holes in the pillars 
CCCC; and it may at pleafure be raifed 
at one end and deprefled at the other. 

HH y Two (traps connected with 
buckles on the oppofite fide for fixing 
the limb after it is properly placed. Be- 
fore laying down the kg, the dreflings 
fhould be all applied, and the excavated 
part of the inftrument fhould be com- 
pletely lined with foft wool. G, A hole 
for receiving the heel to prevent it from 

being 



£02 Explanation of the Plates: 

being hurt when the leg is ftretched out* 
as reprefented in fig. 2. 

The ends, B B, may either be fixed to 
the bafe of the inftrument, or, in order 
to render it more portable, they may be 
made moveable, and fixed for ufe by a 
double pin at each end F. 

Plate LXXXI. 

[Oppofite to page 277.^ 

In Chapter XXXIX. Seclion V. as well 
as in other parts of this work, we had 
occafion to recommend an inftrument 
for fupporting the fore-arm as being pre- 
ferable to any bandage. A reprefenta- 
tion is given of it in fig. I . 

AA)2l cafe or frame of firm leather 
properly lined with flannel and wool, of 
a fufficient length for covering the arm 
from the elbow to the point of the fingers. 
This is intended for the left arm. B, A 
collar of foft buff leather for paffing over 
the right arm, in order to fupport the 
fore-part of the cafe by the ftrap F pa£* 
fing over the left fhoulder, to be fixed to 

* 



Explanation of th6 Plates. 50 J 

fc buckle at C, to prevent the collar B 
from flipping down. G H, Two ftraps 
and buckles for fixing the arm down to 
the inftrument. 

The application of this inftrument 
will be better underftood by the view of 
it in fig. 2. 

I was favoured with this inftrument by 
Dr Monro, to whom, I believe, it was 
fent by Mr Park of Liverpool. 

Figures 3. and 4. Two artificial legs, 
delineated by Mr White of Manchefter 
in his Cafes in Surgery. Fig. 4. A J, A 
hollow leg made of tin, and covered 
with thin leather. B i A leather ftrap 
with a buckle on the outfide, for fixing 
it below the knee. CD, Longitudinal 
fteel bars, to be made as tough and light 
as poflible, with fufficient ftrength. 
Thefe bars are joined by a moveable joint, 
to be placed exactly oppofite to the knee- 
joint. E, A fteel bow made thin and 
elaftic, to pafs about two thirds round the 
lower part of the thigh, and fixed with 
ftraps of leather to buckle on the fore-part. 

Fig. 3. Another artificial leg made in 

the 



504 Explanation of the Plates. 

the fame manner with fig. 4. with the ad* 
dition of a foot made of light wood and 
moveable joints, fo as to imitate pretty 
nearly the natural motions of the joints 
of the ankle and toes. 

Plate LXXXII. 

fOppofite to page 293.] 

Fig. i. A machine invented by an in- 
genious tradefman of this place, Mr Ga- 
vin Wilfon, for diftortions of the leg. 
This fubjedl was treated of in Chapter 
XLI. A A, A cafe of firm leather open 
before, for receiving the diftorted leg 
and foot. BC t A fplint of iron for gi- 
ving an additional firmnefs. The leg be* 
ing placed in this cafe, the foot is fixed 
down to the bottom or fole of it by the 
flrap //pafled through the hole /; and 
the leg itfelf is gradually drawn either to 
one fide or another according to the na- 
ture of the diftortion, and fecured by a 
proper application of the (traps DF, to 
be fixed upon the brafs hooks G E. By a 
due perfeverance in the ufe of this ma- 
chine * 



Explanation of the Plates, 505 

chine, many bad cafes of diftorted limb* 
have been completely cured. 

Fig. 3. A pair of {hoes which have pro- 
ved fef viceable in fome cafes of diftortions 
of the ankle-joint, where the toes have 
been turned too much inward. As they are 
light they may be ufed even in early infan- 
cy. After the feet are fixed in the fhoes 
by the laces before, the toes may be fepa- 
rated to a proper diftance, and preferved 
in this fituation by the apparatus at A ; 
which confifts of three fmall iron plates, 
inore particularly delineated in fig. 5. and 
at B, fig. 4. Fig. 5. confifls of two parallel 
thin plates, fixed with nails to the outfide 
of the fole of one Ihoe ; and they are 
fo far feparated from each other, as to 
receive the round plate B between them, 
the end of which is fixed to the fole 
of the other lhoe. The three plates are 
Connected together by a nail paffmg 
through the hole in the centre of 
each. This admits of a confiderable 
degree of motion, by which the toes may 
be moved either outward or inward ; but 
they can be eafily fixed at any particular 

Vol. VI. K k point 



506' Explanation of the Plates. 

point by a fmall iron pin A patted thro* 
one or other of the holes in the fide of 
the plates-i?; 

Plate LXXXIII. 

[Oppofite to page 296.J 

In this Plate I have delineated an ap- 
paratus mentioned in Chapter XLI. for 
diftortions of the legs. 

Fig. 1 . A B, An iron fplint properly co- 
vered with foft leather fixed in an iron 
frame C. The fplint may be made to fix 
6n either fide of the frame according to 
the nature of the curvature. In a diftort- 
ed leg the foot is to be fixed down to the 
frame C by means of the fhoe repre- 
fented in figure 3. This is eafieft done 
by paffmg a nail through the heel of the 
fhoe into the frame, upon which the fhoe 
may move. If the leg is bent outward, the 
fplint AB, fig. 1. is placed on the infide, 
and it fhould be of fuch a length that the 
pad B may reft upon the internal condyle 
of the knee joint, where it fhould be fix- 
ed by the ftrap E. When the bones are 

bent 



Explanation of the Plates. 507 

bent inward, the fplint muft be placed 
on the outfide of the leg. 

The ftraps EF muft be pafTed two 
or three times round the convex part of 
the leg, and mould be made to prefs it 
with fome degree of force toward the 
fplint ; and by increafing the prefTui e 
from time to time, the convexity or cur- 
vature will be gradually lefTened till at 
laft it may in many inftances be totally 
removed. By means of the ftrap C, the 
toes are to be drawn from that ficfe 
to which they incline, and fixed to 
the oppofite fide of the frame. The 
fcrew-nail D determines what is gained' 
from time to time, by moving it from 
one hole in the frame to another. 

Fig. 4. A machine invented by the late 
Mr Gooch, for giving fupport to weak 
limbs as well as for removing distortions. 
AAA, Three fleel-bows made thin and 
very elaftic : They muft ft'and clear of 
the tibia ; mufl pafs about half round the 
limb, and be fixed with ftraps of leather 
upon round-headed pins. 



508 Explanation of the Plates* 

BBB, A longitudinal plate, to be made 
©f tough fluff, as the workmen term it, 
and as light as poflible with fufEcientr 
ftrength. 

C, The fhank to pafs into the focket, 
in that part of the machine which is to 
be fixed into the heel of the fhoe or la- 
ced boot, and confined there by a fcrew 
at the bottom, 

D, The fcrew to keep the fliank m the 
foeket. 

Plate LXXXIV. 

[OppoGte to page 339.] 

Fig. 1. A. fmall fpring-faw ufed in am- 
putating the fingers and toes. 

Fig. 2. and 3. Retractors made of thin 
iron plates for drawing up and fupport- 
ing the mufcles and other foft parts in 
amputating limbs while the faw is applied 
to the bones. They fhould be kept with 
openings of different fizes, fo as to an- 
fwer where the bone is large or finally 
or whether there be two bones or only 
©ne. 



Explanation of the Plates* 509 

Fig. 4. A piece of firm flit leather, 
which anfwers the purpofe of a retractor 
extremely well. It is better fuited for 
this than a bit of linen, which is gene- 
rally ufed, but which does not fupport 
the parts with fufficient firmnefs. 

Plate LXXXV. 

[Oppofite to page 341.] 

Pig. i. The faw I always ule in th« 
amputation of legs and arms : It fhould 
be feventeen inches in length, including 
the handle, and two inches and a quartet 
in breadth at its # broadeft part. . 

Fig. 2. A fmall double-edged knife, 
commonly termed a Catline, for the pur- 
pofe of dividing the interofleous liga- 
ments and other foft parts in amputating 
the leg and fore-arm : It fhould be nine 
inches long. 

Fig. 3. An amputating knife, which an- 
fwers either for the thigh, leg 7 or arm: 
It fhould be thirteen inches in length. 

Fig. 4. A fmall crooked knife for fe- 

narating the mufcles from the bone in 

K k 3 tbe 



|lo Explanation of the Plates. 

the manner I have advifed in the Chap* 

ter on Amputation, Section IV. 

«*> ,. i i , , • 

Plate LXXXVI. 

[Oppofite to page 439]. 

In chapter XLV. I gave fome account 
of an ingenious propofal by Mr Moore of 
London for diminifhing and preventing 
pain in feveral operations of furgery. It 
is done by compreffing the nerves of the 
limb upon which an operation is to be 
performed. In this Plate I have repre- 
sented the apparatus recommended by 
Mr Moore for this purpoTe. 

Fig. 1. A, The compreffing inftrument, 
being formed of a curved piece of iron 
"covered with leather, and of fumcient 
capacity to contain the thigh within its 
curve. 

B, A firm comprefs of leather at one 
extremity of the inftrument, to be pla- 
ced on the fciatic nerve. 

Z), An oval comprefs fixed on a fcrew, 
pafiing through a hole at the other ex- 
' • "'"' tremity * 



'Explanation of the Pldtss* 5-1 1 

tremity of the inftrument. This com- 
prefs to be placed on the crural nerve. 

When this inftrument is to be ufed, it 
will be necefTary in the firft place to 
fearch for the fciatic nerve : For this 
purpofe let the operator feel for the tu- 
i>erofity of the ifchium, and then for the 
great trochanter ; and fuppofing a flraight 
line drawn from the one to the other, 
apply the comprefs B about an inch above 
the middle of that line. 

The crural nerve is found by the pul- 
iation of the crural artery, which runs 
contiguous to it ; the oval comprefs D 
mull next be applied above it ; and upon 
turning the fcrew connected with it, the 
fciatic nerve is prefTed by B againft the 
edge of the fciatic notch, and the crura.1 
nerve againfl: the os femoris to any de- 
gree that is necefTary. 

Fig. 2. Reprefents the inftrument ad- 
jufted to the thigh ; and fig.. 3. a fmaller 
;ComprefTor fuited to the arm. 

K k 4 Pxat,e 



512 Explanation of the Plates,. 

Plate LXXXVII. 

[Oppofite to page 441.J 

In this Plate I have given a reprefen- 
tation of an artificial leg and arm made 
by a very ingenious artift of this place, 
who I have in different parts of this 
Work had occafion to fpeak of, Mr Ga- 
vin Wilfon. 

Fig. 1 . An artificial leg made of firm 
hardened leather. 

J, An oval piece of the fame kind of 
leather lined with fhamoy, fixed upon a 
plate of iron C, and moving 'upon an 
axis at the knee. The ftrap /, with the 
buckle connected with it, ferves to fix it 
to the thigh. There muft alfq be an 
oval piece connected with a fimilar iron 
plate on the oppofite fide of the thigh : 
Thefe iron plates and oval pads fhoukj 
together go about nine inches up the 
thigh. 

B, A ftrap that comes from the fole of 
the foot, and goes up on the infide of the 
teg to the middle of the thigh, where it 

if 



Explanation of the Plates* 513 

is fixed by a buckle to a ftrap coming 
from the oppofite moulder : This ferve$ 
to fupport the leg, and to take the weight 
pf it more effectually from the weak fide 
than any invention I have met with. 

Fig. 3. The oval piece pf leather and 
jron fplint to which it is fixed. 

Fig. 4. A piece of foft ihamoy leather 
which fixes by a buckle and ftrap round 
the condyles at the knee. In legs of this 
kind, the perfon's weight refts upon the 
Condyles and patella, the ftump itfelf 
hanging quite free within the leg. This 
band or ftrap ferves in the moft effectual 
manner to prevent pain and excoriation, 
which otherwife would probably enfue 
from the friction of the leg againft the 
knee. 

Fig. 2. A fore-arm and hand made of 
the fame kind of leather, and made to 
fix to the arm and fhoulder by the ftraps 
BE. 

Thefe artificial legs and arms are pre- 
ferable to any I have ever feen. The 
leg, when properly fitted, proves equally 

ufeful 



514 Explanation of the Plates. 

ufeful with the common timber leg, and 
it is preferable from being neater ; at the 
fame time that it is not liable to break, an 
accident to which the others are very lia- 
able : and it anfwers better than a leg 
made of copper, from being confiderably 
lighter, and not apt to be hurt in its fhape 
by bruifes. 

Mr Wilfon makes three different kinds 
of legs correfponding to the part at which 
the limb is amputated. In amputating 
the leg lower than the ufual part, that 
is, in fuch a manner that the motion of 
the knee is to be retained, it anfwers 
better at the diflance of nine or ten inches 
from the condyles of the knee than either 
higher or lower. When higher, the re- 
- maining part of the leg is not fufficient to 
fupport the artificial leg in walking ; and 
when much lower, it renders it neceffary 
to make the machine thicker about the 
ankle than would otherwife be required, 
by which it is rendered clumfy and heavi- 
er. Fig. 1. in this plate reprefents a leg 
for this part. 

The fecond kind of artificial leg made 

b 7 



Explanation of the Plata. 515 

by Mr "Wilfon is intended for thofe cafes 
where the amputation has been perform- 
ed at the ufual place below the knee, 
where the weight of the body refts upon 
the knee-joint and upper part of the leg 
upon a foft-ftufFed cufhion. 

Thefe legs have no flexion at the 
knee, and the hollow for receiving the 
thigh goes up near to the hip : It opens 
behind to admit the thigh ; if is fixed 
with three ftraps and hooks, which laft 
are not only ftronger, but lefs bulky than 
buckles. 

When a limb is amputated above the 
knee, a joint is formed in the artificial 
leg at the knee. In walking, the limb 
is made fteady by a fteel bolt running in 
two ftaples on the outfide of the thigh 
being pufhed down ; and when the pa- 
tient fits down, he renders the joint flex- 
ible by pulling the bolt up. This is ea- 
fily done, and it adds much to the utility 
of the invention. 

The reft or fupport in this leg is obtain- 
ed in part from its embracing the upper 

part 



ji(5> 'Explanation of the Plates* 

part of the thigh tightly, but chiefly from, 
the back part of the thigh-box being Huff- 
ed in fuch a manner that the lower part 
of the hip refts upon it with nearly the 
fame eafe that one does in fitting on a (luff- 
ed chair ; and in fact, a perfon fits on it 
when he either (lands or walks ; by which, 
and by the (Irap carried up from the fole 
of the foot to the fhoulder, the limb is 
very eafily carried about. 

Mr Wihon's artificial arms, befides ber 
ing made of firm hardened leather, are 
covered with white lambfkin, fo tinged 
as very nearly to refemble the human 
fkin. The nails are made of white horn, 
tinged in fuch a manner as to be a very 
near imitation of nature. 

The wrift-joint is a ball and focket, and 
anfwers all the purpofes of flexion, exten- 
sion and rotation. The firft joints of 
the thumb and fingers are alfo balls and 
fockets made of hammered plate-brafs, 
and all the balls are hollow to diminifh 
their weight. The fecond and third joints 
^re fomewhat fimilar to that which anato- 

mfk 



Explanation of the Plates. $iy 

mifts term Ginglimus, but they are fb 
far different as to admit of any motion^ 
whether flexion, extenfion, or lateral. 

The fingers and metacarpus are made 
up to the fhape, with foft fhamoy leather 
and baked hair. In the palm of the hand 
there is an iron fcrew, in which a fcrew- 
nail is occafionafly fattened. The head 
of this nail is a fpring-plate, contrived in 
fuch a manner as to hold a knife or a 
fork, which it does with perfect firm- 
nefs. And by means of a brafs ring fix- 
ed on the firft and fecond fingersr, a pea 
can be ufed with fufEcient exactnefs for 
writing. 

When only a hand and fore-arm is need- 
ed T it is fixed to the arm above the elbow 
by a flrap of leather fewed to one of the. 
fides of the artificial fore-arm- After 
making a turn and a h*lf juft above the 
elbow, the ftrap is fixed on the back part 
©f the limb at Z), fig. i. 

When the arm is amputated above the 
elbow, the artificial limb is made with an 
elbow-joint. This part of it is made of 

wood, 



§ 1 8 Explanation of the Platetl 

wood, and has a rotatory motion as well 
as that of flexion and extenfion. 

I have given this particular account of 
Mr Wilfon's invention, from a conviction 
of its being fuperior to any with which 
the public is acquainted : I am alfo 
pleafed at having it in my power to let 
the merit of fuch an artift be more ge- 
nerally known than it otherwife might 
be. Indeed his merit in matters of this 
kind is fo confpicuous, as well as in the 
management of diflorted limbs, that his 
death I would conlider as a public lofs, at 
the fame time that I have often wifhed 
that fome public encouragement were 
given him, to enable him to communi- 
cate as much as poffible the refult of 
his experience to others. 

Plat,p LXXXVIII. 

[Oppofite to page 445.J 

In this plate I have delineated two 
machines for fupporting the head and 
moulders, commonly employed in diftor- 
tions of the fpine. 



Explanation of the Ptatei. 5 1§ 

Fig. 1. J, An iron collar properly co- 
vered for pafling round the neck. By- 
means of the long iron plate connected 
with it, it may be raifed or deprelTed at 
pleafure. BBB, A broad iron plate fitted 
to the back and moulders. CC, Two ftraps 
to be carried over the moulders ; and be- 
ing brought through beneath the arm- 
pits, to be fixed, of a fufficient tightnefs, 
on two knobs on the moulder-plates, as 
may be feen in fig. 2. D, A flrapfor fix- 
ing the plate going down the back, by 
being tied round the body. 

Fig. 3. An iron or fteel inflrument, de- 
lineated by Heifter for the fame purpofe 
with the preceding. A A, Its tranverfe 
part, to which are fattened iron rings CC 
for retaining and keeping back the moul- 
ders. 2?, The perpendicular part going 
down the back. D, A band or ligature 
pafling through an aperture in the lower 
end of the plate B for tying it firmly to 
the body. 

Plate 



520 Explanation of the Plates. 



Plate LXXXIX. 

[Opposite to page 449.] 

In this and the four following plates* 
I have delineated the inftruments em- 
ployed in midwifery. 

n The forceps is perhaps the belt, as it 
is the fafeft, inftrument employed by the 
Accoucheur. 

• Various forms of it have been recom- 
mended by praaitioners j but the one de- 
lineated in this Plate has been found to 
anfwer perhaps better than any other. 
It appears to be fufficiently long, and die 
blades apply with perfect exaftnefs to 
the child's head. 

This inftrument mould meafufe eleven 
or twelve inches in length. Some have 
alleged that they iliould be longer, in 
order to prevent their locking within 
the vagina, and that they may with 
more eafe be applied when the head of 
the child lies high in the pelvis j but the 

length 



Explanation of the Plates. 521 

length we have mentioned is by expe- 
rience found to be fufficient. 



Plate XC. 

[Oppofite to page 452.] . , 

Fig. i . A fingle blade of the common 
crotchet: An inftrument employed for 
tearing away the foetus piece-meal when 
it cannot be delivered entire. From the 
form of this inftrument, it is obvious that 
it cannot be ufed but with much rifk even 
of hurting the mother. The bell rule for 
preventing this is to keep the point of it 
always towards the foetus. 

Fig. 2. The two blades of the crotch- 
et locked together ; in which way they 
may be ufed with perfect fafety to the 
mother. 

Fig. 3. ScifTars ufed for perforating the 
fkull of the foetus, where the pelvis is lb 
narrow that delivery cannot be other- 
wife accomplifhed. After emptying the 
cranium of its contents, the child is ex- 
tracted piece-meal either with the crot- 
chet or with the blunt - hook, fig. 2, 

Vol. VI. LI' PUte 



522 Explanation of the Plates. 

Plate XCI. or with the forceps, figure r, 
or 3. of the fame Plate. 

The fciffars here reprefented are thofe 
recommended by Doctor Denman. 

Plate XCI. 

£Oppofite to page 456.] , 

The forceps, figures I . and 3. as well 
&s the blunt-hook, figure 2. of this Plate, 
are intended, as was mentioned in the 
explanation of the preceding Plate, for 
extracting the foetus piece-meal, when it 
has been judged proper to accomplilh de* 
livery in this manner. 

Plate XCII. 

[Oppofite to page 459 ~\ 

The inftruments in this Plate, and the 
fillet %. 3. in Plate XCIII. are the in^ 
vention of my friend Sir Thomas Bell, a 
practitioner of eminence in Dublin. They 
are chiefly intended for extracting the 
head of the foetus, when by accident or 
Improper management it is feparated 

from 



Explanation of the Plates. 523 

from the body in cafes of narrow pel- 
vis. 

By a proper application of the fillet 
jufl mentioned, he fixes the head fteadi- 
ly till it be fufficiently opened for dis- 
charging the brain ; when by means of 
the forceps here delineated, he performs 
the extraction. Thefe forceps confift of 
two blades ; one nearly of the ordinary 
form ; the other convex : and its con- 
vexity being adapted to the concavity of 
the other, the two occupy much lefs 
fpace than they otherwife would do ; by 
which they are peculiarly well fitted for 
the narrow pelvis we are now fpeaking 
of. The teeth with which one of the 
blades is furnifhed, give thefe forceps a 
very firm hold of any part to which they 
are applied : And as it is an inflrument 
that may be ufed with fafety, I think 
it probable that it may in many cafes 
fuperfede the ufe of the crotchet. 



L 1 2 Plate 



524 Explanation of the Plates* 



Plate XCIII. 

[[Oppofite to page 462] 

Fig. 1. A fillet of whale-bone covered 
with a fheath, which by fome operators 
is employed, in cafes of difficult labour, 
for pulling down the head of the foetus. 
In general, however, the forceps is pre-> 
ferred to it 

Fig. 2. A curved inftrument, with an 
opening at one end, for applying liga- 
tures round polypous excrefcences in the 
uterus. It is the invention of the late 
Doctor Hunter of London, and it anfwers 
the purpofe in the eafieft and moft effec- 
tual manner. 

Fig. 3. A fillet mentioned in the ex- 
planation of the preceding plate as the 
invention of Sir Thomas Bell of Dublin : 
It is a material improvement of the 
common fillet reprefented in figure I. of 
this Plate. 



Plate 



Explanation of the Plates. 525 

Plate XCIV. 

[Oppofite to page 473 .] 

Fig. I. I have here delineated a night- 
cap, fixed in fuch a manner as to ferve 
as one of the befl bandages for the head. 

Fig. 2. The common triangular nap- 
kin, or couvre-chef of the French, ufual- 
ly employed as a bandage for the head. 

Fig. 3. The radiated bandage, as it is 
"ufually termed. It is commonly em- 
ployed for compreiTing the temporal ar- 
tery; and it will anfwer equally well 
for flopping hemorrhagies in any arte- 
ries of the head, as may be feen in fig. 4. 
where the knot or turn is made at the 
angle of the jaw. 

Fig. 5. The bandage ufually employ- 
ed for fractures of the lower jaw, as well 
as for wounds and other injuries of the 
under lip and chin. The method of ap- 
plying it is mentioned in page 475. 

Fig. 6. A bandage for {importing the 

head. It is formed by a proper appli- 

L13 cation 



526 Explanation of the Plates, 

cation of the double-headed roller, fig. 2. 
Plate XCV. 



Plate XCV. 

£Oppofite to page 476.3 

Fig. I. A common fingle-headed roller ; 
a bandage that anfwers for various pur- 
pofes in furgery. 

Fig. 2. A double-headed roller. 

Fig. 3. A double-headed roller with a 
flit in the middle, forming what is term- 
ed the Uniting Bandage. 

Fig, 4. A four- headed roller, ufually 
employed for fractures of the lower 
jaw and other affections of the conti- 
guous parts. 

Fig. 5. A bandage with twelve heads 
or tails applied to a leg. This, as we 
have had occafion to obferve in various 
parts of this work, is the moft ufeful 
bandage for fractures, as well as for 
many other affections of the thighs and 
legs. In fig. 7. I have reprefented a 
bandage of the fame kind, made in a 

manner 



Explanation of the Plates. $ij 

manner commonly ufed in fome of the 
London hofpitals. 

Fig. 6. The uniting bandage, fig. 3, ap- 
plied to a wound in the arm. 

Plate XCVI. 

[Oppofite to page 478.] 

Fig. 1. and 2. A front and back view 
of the napkin and fcapulary bandage ; 
the raoft ufeful bandage for almofl every 
part either of the thorax or abdomen. 
The particular parts of it, and mode of 
applying it, have been already defcribed, 
page 478. 

Figures 3. and 4. different forms of 
the T-bandage. This bandage proves 
particularly ufeful in affections of the 
anus and perineum. , C, A hole for admit- 
ting the penis. At Z), that part of the 
bandage which paffes between the legs 
is divided into two ; one part of it pa£- 
fing on one fide of the penis and fcro- 
tum, and the other on the oppofite 
fide. 

W 

Plats 



528 Explanation of the Plates. 
Plate XCVII. 

[Oppofite to page 480.3 

In this Plate I have delineated the dif* 
ferent forms of fufpenfory bandages for 
the fcrotum. They may be made either 
of linen, cotton, or flannel ; but foft cot- 
ton anfwers belt. 

Each bandage confifts of a circular A, 
which is fixed round the body above the 
bones of the pelvis, and a pouch or bag 
connected with this : The principal dif- 
ference between them confifts in the 
form of the pouch, and in the manner 
by which it is fixed to the circular. In 
figivres I. 2. 3. and 4. the pouch is con- 
nected with the circular both before and 
behind. Of thefe, fig. 3. I think is the 
bed. 

Where the fcrotum is of fuch a fize, 
that the pouch or bag, when fixed upon 
it, will remain, the two bands, which pafs 
between the thighs for fixing it behind, 
are unneceflary : Fig. 5. reprefents a form 
of it for this purpofe. 

^LATES 



,ATKVXC VIIL. 




Fig. *. 



Fig. 



FIG. 



w 




Explanation of the Plates. 529 

Plates XCVIII. and XCIX. 

[[Oppofite to pages 528. and 529.] 

In thefe two Plates I have delineated 
inflruments for a pocket-cafe, which fur- 
geons have daily occafion for. 

Plate XCVIII. fig. i. Forceps. Fig. 2. 
A round-edged fcalpel. Fig. 3. Crooked 
fcifTars. Fig. 4. A cafe for cauftic and 
red precipitate. 

Plate XCIX. fig. 1. and 3. Different 
forms of probes. Fig. 2. A fpatula. Fig. 4. 
A director. 

Thefe, with a probe -pointed bifloury, 
fig. 2. Plate VII. ; a tenaculum, Plate I. 
fig. 1 . ; a fcarificator, Plate XLIX. fig. 4. 
and a few crooked needles of different 
fizes, form a very complete fet for a 
pocket-cafe. 



£ I N I $. 



DIRECTIONS to the BOOKBINDER, 



»late LXX. 


to face page 86 


LXXI. 


96 


LXXH. 


100 


LXXUI. 


109 


LXXIV. 


122 


LXXV. 


I29 


LXXVI. 


I40 


LXXVIT. 


I48 


Lxxvm. 


236 


LXXIX. 


1 - 34^ 


LXXX. 


200 


3LXXXI. 


377 


LXXX II. 


393 


lxxxiii. 


396 


LXXXIV. 


339 



plate LXXXV. to face page 341 



LXXXVI. 


439 


Lxxxvir. 


441 


LXXXVM. 


445 


LXXXIX. 


449 


XC. 


45* 


XCI. 


456" 


XCII. 


459 


XCHI. 


462 


XCIV. 


473 


xcv. 


476 


XCVI. 


478 


XCVII. 


48* 



xcviii.aixcix. 528,52* 



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